To use this article in a citation:

Van Wyngaard, A., 2004. Why are we losing the battle against AIDS? REC Focus. 4:1 (February), 89–97.

WHY ARE WE LOSING THE BATTLE AGAINST AIDS?

Dr Arnau van Wyngaard

In, what must have been one of the most distressing articles I ever read on the topic of AIDS in Swaziland, someone wrote the following in a local Swaziland newspaper, under the heading THE PLAGUE ON AFRICA:

A lament rises every Sunday at dawn from the half-dark valleys of Swaziland, a lament so sweet, says local resident Jane Slabbert, that it seems to carry the souls of the dead up to heaven. It rises here, there, everywhere from the processions of mourners who make their way from village to grave side.

Saturday night has become the night of vigils, of traditional Swazi wakes, when friends and relatives gather to feast and to mourn the deaths of young people, the cream of the nation. As the AIDS pandemic gathers pace, Swaziland has entered an endless season of mourning.

The vigils are announced publicly in death notices that fill a page, or often two pages, in the local newspapers every day. Many are accompanied by photographs which show that almost all the victims are in their twenties or early thirties. The language of the announcements is both quaint and evasive: George Shongwe is late; Zodwa Madolo, nee Diamini, died suddenly and is late, Cynthia Zwane is late. Friends and relatives are informed that the vigil will be on Saturday night, the funeral early the next morning.

There is no hint of the cause of these deaths, though everybody knows. The universal human response to AIDS is denial. It is as though nobody can face the awful reality of a calamity that rivals the great plagues of history.

I study the newspaper announcements intently, trying to wring some meaning from the photographs, but they are mute. Like those sepia photographs of young lieutenants who died in the First World War, these images demand an effort of imagination to evoke the underlying tragedy. They show healthy young people, some wearing their mortar boards at graduation, others in suits, open-faced and healthy. The likenesses have been chosen not to illuminate tragedy or to define an epidemic, but to preserve a memory of happier times. They, too, serve to conceal the awful,

unacceptable truth: an entire generation of young Swazis is dying.

Why, after having known about this problem for more than fifteen years, does it seem as if AIDS cannot be conquered in Africa? After having made a study of this topic, I consider the following as some of the main reasons why it seems as if we are losing the battle against HIV/AIDS in Africa:

1.     DENIAL

Denial is often considered to be the number one enemy hindering progress in the battle against AIDS. Denial occurs on many levels:

1.1           Denial by those not affected by AIDS

It is well known that individuals experiencing a personal crisis such as cancer go through a long process consisting of different phases. They usually start by denying the problem (It can’t be; the doctor is wrong), then move to anger (Why did this happen to me; I hate God), and after a number of other steps eventually get to the point where the inevitable is accepted (I have cancer -1 must start planning my life accordingly). In the case of a national disaster such as AIDS, where not only an individual or a family, but entire communities and ultimately entire countries are affected, this same process seems to occur within such communities. While some people have progressed to the anger stage (AIDS is God’s solution for the over-population of Africa, or I have AIDS. I’m not willing to die alone, therefore I will infect as many people as possible while I have the opportunity to do it), the majority still seem to be in the denial phase of the process. When discussing this problem with Western people, I often find a total disbelief about the disastrous effects which AIDS has in Africa. The words of a white minister with whom I discussed this problem recently, sums it up very well, when he said to me: “The people telling us about AIDS are exaggerating when they give us the statistics. They are simply playing with numbers!”

1.2           Denial by countries affected by AIDS

The tendency in the past has been for entire countries in Africa to deny the existence of AIDS. The reasons are numerous. From a mere economic perspective, it can easily be understood that those in control of a country would try to hide the true effects of AIDS. Who would invest in a country that is slowly but surely dying? From a psychological perspective, it is also understandable that a country's government would prefer to deny the impact of AIDS: To admit that you are losing the battle against AIDS may be interpreted as an admission of incompetence to rule the country. The denial of AIDS may also be linked to a historical perspective: People like Baffour Ankomah, publisher of New African, consider AIDS as “U.S. biological warfare gone wrong.” Millions of Africans have long memories of Western evils: slavery, colonial exploitation, Cold War proxy battles and biological warfare tests carried out by white-minority regimes. Ankomah considers AIDS as the latest of these: a money-making hoax carried out by the United Nations at Africa’s expense.

Many Africans also have an emotional reaction to the theory that AIDS originated in the blood of chimpanzees in central Africa, probably in eastern Zaire in the late 1970s, and jumped to Africans. To many Africans, the theory sounds like old racist propaganda that linked black people and apes.

1.3           Denial by individuals affected by AIDS

Many people who are affected by AIDS are desperate to find something to blame for their condition other than their own behavior. To admit the most common cause of AIDS would be an admission of an immoral life.

It is impossible to find a cure for a disease which seemingly “does not exist.” It is equally impossible to have compassion for the victims of AIDS if the problem is still being denied to a large extent. Therefore, before one can seriously look for a solution to the AIDS problem, one will have to find ways of bringing all parties to the point where they admit that AIDS does exist, that it is largely spread through immoral living and that it is a killer disease.

2.      THE TYPICAL ATTITUDE TOWARDS SEX

Sex, in general, is a taboo subject amongst the Africans. In the majority of homes the subject is seldom if ever discussed in a healthy manner. Church leaders warn the youth to live morally correctly, but even these warnings are seldom accompanied by balanced teachings on the Biblical concept of sex and sexuality. In schools, children are taught the biological facts about sexual reproduction, but these facts are mostly not accompanied by Biblical teachings on the topic. From a very small age, children play sexual games with each other, although it was traditionally frowned upon if a young man had intercourse with a girl before marriage.

But things have changed. One aspect I have found to be a tremendous problem in Africa is a lack of respect for other’s privacy. This is often caused by the living conditions of vast numbers of people in Africa, such as the lack of toilets (which means that people relieve themselves in public), the lack of bathrooms (which means that people often wash in rivers and streams) and the lack of bedrooms (which means that children often share their parent’s bedroom or at least that boys and girls, not necessarily from one family, but also members from the “extended family”, share one bedroom). These people grow up within a system where boys and girls, even after puberty, see each other fully or partially unclothed on a regular basis, where they play together in the rivers unclothed, and where they consider all of this to be completely natural. Little wonder that a recent survey done in Swaziland by UNICEF found that, by 18 years of age, for all practical purposes, 100% of girls and 80% of boys have already had sexual intercourse.

3.     MIGRANT LABOR

A tremendous problem with which Africa has to cope is migrant labor. People living in the rural areas need money for food. Because there are few work opportunities in the rural areas, the men will often move out, either to larger towns in their own country or to the mines in South Africa to earn more money. Some of these men visit their homes only over the Christmas season. Some are fortunate enough to come home more regularly. For the rest of the time, they do not see their families.

South Africa’s former official policy of Apartheid contained laws forcing African people to live in certain restricted areas or homelands. Only those who had been issued with passes could enter and work in “White” areas. These laws certainly contributed towards this situation. Men were often accommodated in hostels at their workplace, but their family members were not allowed to stay over in the same premises, as this would be against the laws of the country. Fortunately, the official policy of the country has changed, but the situation remains, to a large extent, the same. A South African lady discussed this with me some time ago and told me that her husband had forbidden her even to come and visit him in Johannesburg where he is working in a mine. But, she told me, she knows the reason for his attitude - he has another woman in Johannesburg! The need (sometimes greed) for money is forcing people to make decisions that break down their family lives. Often even church leaders have made a choice to live in this way. As family life breaks down, immorality increases.

4.     PROSTITUTION

Closely linked to migrant labor is the problem of prostitution. Where married men live apart from their wives, the non-Christian, and even some Christians, make use of prostitutes or get a girlfriend living close by as a sexual outlet. At mine and other hostels, so-called “sex workers” have an open door to do business. In larger cities, “escort ladies” also have a roaring business. But then again, while people are poor, prostitution will always be an “easy” way to earn big money. The girls are therefore only too eager to give themselves to the men. This becomes a vicious circle.

5.     BREAST FEEDING

Another tremendous problem in the whole of Africa is that it has now become clear that HIV can also be spread through breast feeding. It has been found that 36% of the children with HIV were infected with the disease through breast milk from their HIV+ mothers. The obvious solution is for mothers who are HIV+ not to breast-feed their babies any longer. But things are not quite as simple. For women staying in rural areas there is no other option than to breastfeed their children. The choice is: lose your child through HIV or lose your child (perhaps even earlier!) through malnutrition, typhoid, cholera or similar diseases. Milk formula is also too expensive for the majority of people living in the rural areas. Even if the milk formula should be given to HIV+ mothers free of charge, it still has to be mixed with water. Where there is no pure water in the rural areas, it means that water from the rivers have to be used. However, upstream one will find cattle walking in the river and often these rivers are also used by humans as toilets. Bilharzia is also common in virtually all rivers in sub-Saharan Africa. Therefore, if milk formula is given to a baby, and the water has not been purified or boiled for a very long time, the baby will become ill and can even die. A second problem is the cleaning of bottles. In the Western culture all kinds of methods are used to ensure that feeding bottles are clean. A whole training course will need to be undertaken in Africa if mothers want to ensure that they feed their children with sterilized bottles.

Researchers now recommend that African women with HIV breast-feed exclusively for six months, using techniques that minimize cracked nipples, then abruptly wean. Doing so could reduce the HIV transmission risk to as low as 6 percent. Anything else given to an infant - water, bits of porridge or cooking oil (often given to combat constipation) irritate the lining of the gut, increasing the possibility that the baby’s body will absorb the HIV virus through the milk. So researchers are now proposing that women practice exclusive breast feeding and abrupt weaning. That is, nothing at all except breast milk for six months, and then an abrupt cutoff. Medically, this method has been proved to be effective in reducing the risk of mother-to-child transmission of HIV. However, especially in the rural areas, it is highly unlikely that this method will be implemented. In most, if not all sub-Saharan African countries, breast feeding is as normal as having a cup of tea. When a baby is unhappy, the mother breast-feeds the child. This happens publicly, in church, on the bus or wherever they are. To change this custom will not be easy. A total paradigm shift will have to take place in most cultures, which may be possible on the long term, but definitely not on the short term.

The only other possible solution at this point, other than convincing a mother not to breast-feed at all or to practice exclusive breast feeding for six months and then weaning abruptly, is to supply an antiretroviral drug to both mother and child. At present nevirapene seems to be one of the most effective drugs used for this purpose. A single dose is given to the mother at the onset of labor and a single dose is given to the baby 48 to 72 hours after birth. Tests have shown that there is a substantial decrease in the chance of a baby getting HIV from the mother if nevirapene is administered in this way.

Unfortunately a new problem has now arisen. In a medical research paper published in February 2003, it was reported that the most important resistance mutation to nevirapene has been detected in the breast milk of at least 70% of women forming part of a test group in Zimbabwe. This means that nevirapene may not be effective for much longer to prevent mother-to-child transmission of HIV. Breast feeding, central in the raising of a baby in most African countries, has now become one of the major problems in these countries where AIDS are slowly but surely wiping out large parts of the population.

6.     USELESS METHODS TO PREVENT AIDS

In Swaziland, all kinds of innovative methods are presently being discussed to stop the spread of AIDS. A major problems the country is experiencing is that more than half of all teachers in Swaziland are HIV+, according to some sources. (Similar reports also exist from South Africa). Sexual intercourse between teachers and school children seem to be common. The teachers have money and are able to pay the school girls for their services. In a feeble attempt to try and stop this practice, a new law has been introduced in Swaziland, whereby girls will not be allowed to wear dresses or skirts to school that sit above the girl’s knee. The rationale behind this is that government feels that if the girls’ legs are not showing, then the teachers would not be interested in the girls any longer! Serious discussions are also being held in parliament to consider making forced sterilization a law for all HIV+ people. How this will help in the fight against AIDS was not said. It has also been suggested that all HIV+ people should wear some kind of mark (similar to the yellow stars worn by the Jews in Germany during the Second World War) in order to identify them as carriers of the virus. In South Africa heated debates have been conducted in order to prove that AIDS is not caused by HIV, but that the actual cause is poverty. If poverty could be eradicated, then AIDS will also vanish. It is clear that people are at a loss to know how to handle the situation.

7.     THE MYTH OF “SAFE SEX”

Officially, people are told that the AB C method should be followed in order to prevent AIDS. ABC stands for:

•       Abstinence

•       Be Faithful

•       Condomise

In Africa I have found that only the last method is seriously propagated, more commonly known as “safe sex.” In spite of huge promotional campaigns to convince people to use condoms, even to the extent where bill boards were erected in South Africa with the national flag on it in the shape of a condom, the number of people contracting AIDS are still growing exponentially. There are many reasons why this method is not working. The main reason is probably a cultural one: In Africa the use of a condom is often compared to bathing with your socks on. It is just not part of Africa’s culture to use condoms during sexual intercourse.

In articles and comic strips in which the use of condoms is promoted to address the AIDS problem in Africa, women are encouraged to deny sex to men if the men are not willing to use a condom. In the African culture, where women are taught from young age that they have to respect men. Where they are traditionally considered to be inferior to men, it is extremely difficult for them to apply this in practice. In extensive studies done among people in Africa, it has been found that a woman has very little say about her sex life - even before marriage.

This can clearly be seen in a practice known as “dry sex” and which has been reported in many countries in Southern Africa, including South Africa, Zimbabwe, Malawi, and Zambia. Many women will insert substances, such as household detergents or antiseptics, in their vagina prior to intercourse in order to prevent wetness of the vagina during intercourse. They claim that this produces a “hot, tight, and dry” environment, which their men find more pleasurable. In a survey conducted at various Family Planning Clinics in Zambia, findings revealed that 25% women claimed insertion of substances ranging from dry cloth, chemicals such as dettol, salt, flagyl tablets to herbs to minimize wetness which the men resented. In the survey, 85% of the men preferred dry sex. On the other hand, it was found that only 15% women claimed to prefer dry sex. Most found it painful and only performed it to satisfy their husbands, and to prevent them from finding other partners outside marriage. Due to their financial dependence on men, women are unable to negotiate safety, type or pleasure of sex. Most women do not enjoy dry sex but do it to secure their marriage.

While this illustrates the point that women have very little say about their sexual lives, the further result of this practice is that, if condoms are still used, the risk of the condoms breaking during intercourse becomes much greater. In the survey done in Zambia many participants complained of condom breakage in dry sex experiences. Also, glaring differences were found when comparing HIV rates to similar communities where wet sex was more common. In the group practicing dry sex, there was a 20% HIV prevalence as opposed to 10% in the group practicing wet sex.

Violence against women within marriage relationships are common. Where countries are in a state of war, rape is also much more common, as this is often used as a method of intimidating the enemy. Even in countries not ravaged by war, rape, including the rape of children under the age of sixteen, have increased tremendously over the past few years. Child abuse is also occurring much more commonly.

Another problem is the unreliability of condoms. Some medical reports consider condoms to be around 96% reliable as a birth control method. As a method of protecting someone from HIV, reliability will definitely be much lower. There are two reasons for this: ignorance of the correct use of a condom contributes towards the ineffectiveness of this method, and the poor quality of condoms “dumped” on the African market results in more frequent breakage. Good quality condoms are fairly expensive. Even amongst those, a certain percentage of breakages and slippage are reported. Sex with a condom is undoubtedly preferable to sex without a condom, if you are not 100% sure of the HIV status of your partner, but it cannot be considered as a 100% safe method.

8.     IS THERE AN ANSWER TO THIS PROBLEM?

•        People from a Western background need to understand the disastrous effects of AIDS.

•        People from an African background need to understand more about the causes of AIDS and take responsibility for their part in the spreading thereof.

•        Christians will have to be taught that the acceptance of salvation in Christ needs to be demonstrated in a Godly life.

•        God’s will for marriages should be explained in a way that will really speak to the Africans.

•        God’s will for the family should also be addressed effectively.

•        The problem of migrant labor needs to be addressed and people will have to be convinced that a choice for a lower salary but a more Godly family life is a worthwhile choice to make.

•        Recent research has shown that most Christians (more than 80%) accept Christ as Saviour between the ages of 4 and 14. If we want to win the battle against AIDS, then this is the age to start with.

Table of Contents

- 1. DENIAL

- 1.1 Denial by those not affected by AIDS

- 1.2 Denial by countries affected by AIDS

- 1.3 Denial by individuals affected by AIDS

- 2. THE TYPICAL ATTITUDE TOWARDS SEX

- 3. MIGRANT LABOR

- 4. PROSTITUTION

- 5. BREAST FEEDING

- 6. USELESS METHODS TO PREVENT AIDS

- 7. THE MYTH OF “SAFE SEX”

- 8. IS THERE AN ANSWER TO THIS PROBLEM?

Table of Contents

1. DENIAL

1.1 Denial by those not affected by AIDS

1.2 Denial by countries affected by AIDS

1.3 Denial by individuals affected by AIDS

2. THE TYPICAL ATTITUDE TOWARDS SEX

3. MIGRANT LABOR

4. PROSTITUTION

5. BREAST FEEDING

6. USELESS METHODS TO PREVENT AIDS

7. THE MYTH OF “SAFE SEX”

8. IS THERE AN ANSWER TO THIS PROBLEM?