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Research and analysis on Africa
AIDS Research in the Social Sciences. What Have We Learned in the Last Decade?
By: Bawa Yamba, Social anthropologist, Swedish researcher in the Nordic research group
AIDS in Africa HIV/AIDS is perhaps the worst epidemic that mankind has ever known. It has a global spread and the numbers of people it afflicts are enormous. No part of the world is spared from its scourge, irrespective of whether there are prevalence statistics available from a particular country or not. By the end of 1998 figures released by UNAIDS showed that over 34 million people were infected with the AIDS virus world wide, with each subsequent statistics released surpassing the previous ones. Africa is still the worst affected part of the world, with an estimated 23 million infected. Initially the epicentre of the epidemic was the inter-lacustrine part of central African, particularly around Lake Victoria, and Eastern Africa. This has changed. The most devastating spread of the virus now appears to have occurred in the southern parts of Africa. Botswana, Malawi, South Africa, Zambia and Zimbabwe are now the countries with the highest levels of HIV infection. For example, pregnant women in one urban centre in Botswana have HIV prevalence rates of 48%. Similarly, some surveillance sites in Zimbabwe showed rates between 20 and 50% among pregnant women tested anonymously. South Africa has estimated that 3.6 million South Africans are now living with HIV/AIDS. Only Uganda and Tanzania have reported a limited decrease.
The situation is no less grave in West Africa where, apart from Senegal that has shown some decrease, the epidemic continues to rise in countries such as Côte d'Ivoire, Ghana and Nigeria. These prevalence statistics paint a frightening future picture for the continent. Modest advances in social and economic development that some of these countries have made in recent decades - and the same holds for other aspects of African life - will be wiped out as a result of HIV. Some cultural attributes have changed and will continue to change. One in particular, the extended family system, that used to be regarded as quintessentially African, has virtually ceased to exist as a safety net of support to kinsmen; the principal cause of this being HIV/AIDS. Life expectancy will plunge to levels lower than those of the past before the growth of modern medical facilities. Take Botswana, for example: projections show that with 25% of adults infected with HIV/AIDS, the life expectancy of their children will be around 41 years by the year 2005, lower than in the 1950s. Without HIV/AIDS these children would have lived to be 70. Projections further show that prevalence rates of 10% will cause life expectancy to drop by as much as 17 years. Such are the future scenarios that most African countries face today.
Still no cure and no vaccine
It is now more than a decade and a half since the virus was first detected and its connection to AIDS established, yet there is still no known cure. Vaccines, despite some promising news now and again, appear to be as elusive as ever. The industrialised countries have been successful in delaying the onset of AIDS through anti-retroviral combination therapies, and they have effectively reduced mother to child transmission. The treatment of opportunistic infections and the availability of high quality health care systems have prolonged and improved the quality of life for persons with HIV. But the costs of such drugs are so high that they are beyond the means of most African countries, which belong, in any case, to the poorest in the world. And, even if vaccines were available it would take a long time before they became affordable in Africa.
Women and children, and adolescents belong to the most vulnerable groups in all the countries; there are often many more of them infected than other groups. Husbands infect wives who might pass on their infection to their children; while adolescents, particularly young girls, are sometimes infected by older men, the so-called "sugar daddy" syndrome.
Behavioural change, and education combined with the treatment of sexually transmitted diseases (STDs), has proved to be most effective. Political will and steadfast commitments to fighting the epidemic are key prerequisites for making a difference. This is clear from the few instances where improvements have been reported, marginal though these may be. Uganda and Tanzania are two such countries. The former was one of the first of the African countries to carry out a massive HIV/AIDS prevention programme. There is now some compelling evidence that this is producing some positive results. Political commitment in Uganda is reflected in the fact that the AIDS preven-tion programme is located in the Office of the President. This construction itself lends it the highest authority and enhances the efforts of the programme. In contrast, one finds in other countries that the AIDS control programme is relegated to some remote section of the Ministry of Health, and headed by a relatively junior person. Usually such a person lacks political clout and, therefore, the authority to convene intersectoral groups to discuss HIV/AIDS prevention, and is less likely to be able to put practical AIDS prevention into place.
The entry of the social scientists
Social scientists, to whom I belong, became involved in AIDS prevention research over a decade ago. Some of us were brought in by our medical colleagues. The main reason for this was the increasing realisation that disease prevention was not only a bio-medical issue: how people perceive diseases, whether they would use the modern medical services, and even the definition of ill-health itself - are partly cultural constructions. Without a cure for HIV/AIDS, sexual behaviour change was the principal means for breaking the chain of infection. HIV/AIDS brought this realisation that effective disease prevention requires multidisciplinary approaches and multisec-toral efforts. Nonetheless, AIDS, like diseases in general, remained primarily the domain of bio-medics, who have not only the expertise for dealing with illnesses, but are licensed by society to manage them. The partnership between bio-medics and social scientists, therefore, has been an asymmetrical one, in which the latter have continuously had to legitimate their role in the teamwork. Our bio-medical colleagues have sometimes expressed some dissatisfaction as to our role in AIDS prevention. Some of this criticism is justified. Indeed similar concerns have been expressed by social scientists themselves. It has been held that social scientists have neither been able to produce clear theories nor sustainable models for change of sexual behaviour. This may well be true. Social scientists are primarily not trained to do action research. Research that will bring about change in others' sexual behaviour implicitly assumes that the researchers' own models for behaviour are superior to those of the "Others". This is an aspect of action research that makes social scientists uncomfortable. Yet, without this ethnocentric stance, we cannot conduct research of any relevance to AIDS prevention. To prevent HIV/AIDS we have to start from the premise that there are forms of knowledge and sexual behaviour that are "better" and which, if adopted, will reduce the risk for infection. Some of us have had to accept this intrinsic aspect of our involvement in HIV/AIDS prevention. But if we have not been very successful the constraints under which we labour must be considered extenuating. Another factor worth noting is that sexual behaviour is a very complicated phenomenon. It is an area where biological necessity and cultural imperatives conjoin. Sex might be a biological need, but it is governed by cultural norms. The strength of that biological need, how it is expressed, and with whom we share it, are governed by the culture of the particular societies in which we live. This makes any attempt to promote sexual behavioural change that is predicated on a rational acceptance of disease prevention information rather problematical.
Some contributions from the social sciences
Nonetheless, there is and has been some very good research resulting in contributions to AIDS prevention by social scientists. Some of the strength of such research lies in the construction of interactive methods that have increased the awareness of those studied, on the importance of changing their behaviour. Research of this kind has sometimes made people become aware of the risks of traditional practices. In some cases local people have had to invent new customs that are less risky. New forms of ritual cleansing of widows in Zambia that does not entail sexual intercourse, as was the case in the past, is one such example. Research by social scientists has also shown the interrelation of migrations and HIV/AIDS. Commercial sex workers, and certain cultural practices have been shown to be risk factors for HIV transmission. The "success stories" reported from Uganda and Tanzania were the result of combined efforts by bio-medical experts and social scientists. UNAIDS concludes at the end of a paper on the success in Uganda with the following observation : "The Uganda experience also highlights the importance of gathering parallel sets of data on HIV/AIDS seroprevalence and on behaviour. Each set is valuable on its own, but taken together they provide a much more robust picture in the fight against HIV/AIDS"*. One might add that the importance of political commitment to prevent the epidemic is by far the overriding instrument.
The future?
AIDS still remains the greatest threat to the future of Africa. Despite the vast resources that it attracts from the donors HIV/AIDS is still not accorded the primacy it deserves. The goals of the development aid of most countries include the reduction of poverty, democratisation and human rights, and the promotion of gender equality. But such goals are bound to be eroded by HIV/AIDS. The interrelation of HIV/AIDS with poverty is one observed characteristic of the epidemic. AIDS is still predominantly the disease of the poor among whom malnutrition, little education and lack of access to medical services make them easy prey. What of civil rights which are an intrinsic aspect of democracy? In many African societies, the civil rights of persons with AIDS are severely curtailed. In some cases people who have publicly acknowledged their HIV infection have been publicly humiliated and even killed. Gender equality cannot be achieved with women and children bearing the brunt of infection. Women are further the principal caregivers of persons with AIDS. We need continued research on sexual behaviour and on factors that make HIV/AIDS information successful, but apparently, not internalizable enough so as to bring about change in sexual behaviour. We also need research that will promote and influence policy. However, we have learned over the years that it is one thing to produce research results, and quite another thing to see to it that such results influence policy makers. Perhaps, we need to go back to the drawing board, as it were, and come up with better ways of involving potential policy makers. We may do this by focusing on issues they are interested in, just as we have involved communities in prevention strategies that we think will be sustainable. Such a strategy may mar the academic standards of research. But that is something we will have to live with if we commit ourselves to research on HIV/AIDS prevention. Another way of jolting policy makers into a long-term commitment would be to make it clear to them that their own children and grandchildren can expect to live 17 years shorter lives, and that all they have been working for in their struggle for a better future, will be wiped out by AIDS. Perhaps this will make them more concerned, and then, Africa might have a future.
* A Measure of Success in Uganda: The Value of Monitoring Both HIV Prevalence and Sexual Behaviour, UNAIDS Case Study, May 1998.
AIDS in Africa HIV/AIDS is perhaps the worst epidemic that mankind has ever known. It has a global spread and the numbers of people it afflicts are enormous. No part of the world is spared from its scourge, irrespective of whether there are prevalence statistics available from a particular country or not. By the end of 1998 figures released by UNAIDS showed that over 34 million people were infected with the AIDS virus world wide, with each subsequent statistics released surpassing the previous ones. Africa is still the worst affected part of the world, with an estimated 23 million infected. Initially the epicentre of the epidemic was the inter-lacustrine part of central African, particularly around Lake Victoria, and Eastern Africa. This has changed. The most devastating spread of the virus now appears to have occurred in the southern parts of Africa. Botswana, Malawi, South Africa, Zambia and Zimbabwe are now the countries with the highest levels of HIV infection. For example, pregnant women in one urban centre in Botswana have HIV prevalence rates of 48%. Similarly, some surveillance sites in Zimbabwe showed rates between 20 and 50% among pregnant women tested anonymously. South Africa has estimated that 3.6 million South Africans are now living with HIV/AIDS. Only Uganda and Tanzania have reported a limited decrease.
The situation is no less grave in West Africa where, apart from Senegal that has shown some decrease, the epidemic continues to rise in countries such as Côte d'Ivoire, Ghana and Nigeria. These prevalence statistics paint a frightening future picture for the continent. Modest advances in social and economic development that some of these countries have made in recent decades - and the same holds for other aspects of African life - will be wiped out as a result of HIV. Some cultural attributes have changed and will continue to change. One in particular, the extended family system, that used to be regarded as quintessentially African, has virtually ceased to exist as a safety net of support to kinsmen; the principal cause of this being HIV/AIDS. Life expectancy will plunge to levels lower than those of the past before the growth of modern medical facilities. Take Botswana, for example: projections show that with 25% of adults infected with HIV/AIDS, the life expectancy of their children will be around 41 years by the year 2005, lower than in the 1950s. Without HIV/AIDS these children would have lived to be 70. Projections further show that prevalence rates of 10% will cause life expectancy to drop by as much as 17 years. Such are the future scenarios that most African countries face today.
Still no cure and no vaccine
It is now more than a decade and a half since the virus was first detected and its connection to AIDS established, yet there is still no known cure. Vaccines, despite some promising news now and again, appear to be as elusive as ever. The industrialised countries have been successful in delaying the onset of AIDS through anti-retroviral combination therapies, and they have effectively reduced mother to child transmission. The treatment of opportunistic infections and the availability of high quality health care systems have prolonged and improved the quality of life for persons with HIV. But the costs of such drugs are so high that they are beyond the means of most African countries, which belong, in any case, to the poorest in the world. And, even if vaccines were available it would take a long time before they became affordable in Africa.
Women and children, and adolescents belong to the most vulnerable groups in all the countries; there are often many more of them infected than other groups. Husbands infect wives who might pass on their infection to their children; while adolescents, particularly young girls, are sometimes infected by older men, the so-called "sugar daddy" syndrome.
Behavioural change, and education combined with the treatment of sexually transmitted diseases (STDs), has proved to be most effective. Political will and steadfast commitments to fighting the epidemic are key prerequisites for making a difference. This is clear from the few instances where improvements have been reported, marginal though these may be. Uganda and Tanzania are two such countries. The former was one of the first of the African countries to carry out a massive HIV/AIDS prevention programme. There is now some compelling evidence that this is producing some positive results. Political commitment in Uganda is reflected in the fact that the AIDS preven-tion programme is located in the Office of the President. This construction itself lends it the highest authority and enhances the efforts of the programme. In contrast, one finds in other countries that the AIDS control programme is relegated to some remote section of the Ministry of Health, and headed by a relatively junior person. Usually such a person lacks political clout and, therefore, the authority to convene intersectoral groups to discuss HIV/AIDS prevention, and is less likely to be able to put practical AIDS prevention into place.
The entry of the social scientists
Social scientists, to whom I belong, became involved in AIDS prevention research over a decade ago. Some of us were brought in by our medical colleagues. The main reason for this was the increasing realisation that disease prevention was not only a bio-medical issue: how people perceive diseases, whether they would use the modern medical services, and even the definition of ill-health itself - are partly cultural constructions. Without a cure for HIV/AIDS, sexual behaviour change was the principal means for breaking the chain of infection. HIV/AIDS brought this realisation that effective disease prevention requires multidisciplinary approaches and multisec-toral efforts. Nonetheless, AIDS, like diseases in general, remained primarily the domain of bio-medics, who have not only the expertise for dealing with illnesses, but are licensed by society to manage them. The partnership between bio-medics and social scientists, therefore, has been an asymmetrical one, in which the latter have continuously had to legitimate their role in the teamwork. Our bio-medical colleagues have sometimes expressed some dissatisfaction as to our role in AIDS prevention. Some of this criticism is justified. Indeed similar concerns have been expressed by social scientists themselves. It has been held that social scientists have neither been able to produce clear theories nor sustainable models for change of sexual behaviour. This may well be true. Social scientists are primarily not trained to do action research. Research that will bring about change in others' sexual behaviour implicitly assumes that the researchers' own models for behaviour are superior to those of the "Others". This is an aspect of action research that makes social scientists uncomfortable. Yet, without this ethnocentric stance, we cannot conduct research of any relevance to AIDS prevention. To prevent HIV/AIDS we have to start from the premise that there are forms of knowledge and sexual behaviour that are "better" and which, if adopted, will reduce the risk for infection. Some of us have had to accept this intrinsic aspect of our involvement in HIV/AIDS prevention. But if we have not been very successful the constraints under which we labour must be considered extenuating. Another factor worth noting is that sexual behaviour is a very complicated phenomenon. It is an area where biological necessity and cultural imperatives conjoin. Sex might be a biological need, but it is governed by cultural norms. The strength of that biological need, how it is expressed, and with whom we share it, are governed by the culture of the particular societies in which we live. This makes any attempt to promote sexual behavioural change that is predicated on a rational acceptance of disease prevention information rather problematical.
Some contributions from the social sciences
Nonetheless, there is and has been some very good research resulting in contributions to AIDS prevention by social scientists. Some of the strength of such research lies in the construction of interactive methods that have increased the awareness of those studied, on the importance of changing their behaviour. Research of this kind has sometimes made people become aware of the risks of traditional practices. In some cases local people have had to invent new customs that are less risky. New forms of ritual cleansing of widows in Zambia that does not entail sexual intercourse, as was the case in the past, is one such example. Research by social scientists has also shown the interrelation of migrations and HIV/AIDS. Commercial sex workers, and certain cultural practices have been shown to be risk factors for HIV transmission. The "success stories" reported from Uganda and Tanzania were the result of combined efforts by bio-medical experts and social scientists. UNAIDS concludes at the end of a paper on the success in Uganda with the following observation : "The Uganda experience also highlights the importance of gathering parallel sets of data on HIV/AIDS seroprevalence and on behaviour. Each set is valuable on its own, but taken together they provide a much more robust picture in the fight against HIV/AIDS"*. One might add that the importance of political commitment to prevent the epidemic is by far the overriding instrument.
The future?
AIDS still remains the greatest threat to the future of Africa. Despite the vast resources that it attracts from the donors HIV/AIDS is still not accorded the primacy it deserves. The goals of the development aid of most countries include the reduction of poverty, democratisation and human rights, and the promotion of gender equality. But such goals are bound to be eroded by HIV/AIDS. The interrelation of HIV/AIDS with poverty is one observed characteristic of the epidemic. AIDS is still predominantly the disease of the poor among whom malnutrition, little education and lack of access to medical services make them easy prey. What of civil rights which are an intrinsic aspect of democracy? In many African societies, the civil rights of persons with AIDS are severely curtailed. In some cases people who have publicly acknowledged their HIV infection have been publicly humiliated and even killed. Gender equality cannot be achieved with women and children bearing the brunt of infection. Women are further the principal caregivers of persons with AIDS. We need continued research on sexual behaviour and on factors that make HIV/AIDS information successful, but apparently, not internalizable enough so as to bring about change in sexual behaviour. We also need research that will promote and influence policy. However, we have learned over the years that it is one thing to produce research results, and quite another thing to see to it that such results influence policy makers. Perhaps, we need to go back to the drawing board, as it were, and come up with better ways of involving potential policy makers. We may do this by focusing on issues they are interested in, just as we have involved communities in prevention strategies that we think will be sustainable. Such a strategy may mar the academic standards of research. But that is something we will have to live with if we commit ourselves to research on HIV/AIDS prevention. Another way of jolting policy makers into a long-term commitment would be to make it clear to them that their own children and grandchildren can expect to live 17 years shorter lives, and that all they have been working for in their struggle for a better future, will be wiped out by AIDS. Perhaps this will make them more concerned, and then, Africa might have a future.
* A Measure of Success in Uganda: The Value of Monitoring Both HIV Prevalence and Sexual Behaviour, UNAIDS Case Study, May 1998.