Sex, drugs and transfusions (and don’t forget circumcision and condoms): what explains high HIV in Sub-Saharan Africa?
By Fiorenzo Conte
The discussion surrounding the reasons of a high HIV/AIDS prevalence rate in East and Southern Africa is often fed by misconceptions and myths. The book Wisdom of Whores makes a great job at reminding us what we know about HIV/AIDS transmission mechanisms.
“To take up residence in someone else’s body, HIV more or less needs to be invited in through an open door. And injections aside, there are not all that many things that can open a door. The main ones are small tears and lesions around our genitals (or in our anus, in the case of anal sex), and the presence of cells which are especially welcoming to HIV…The other things that poke holes in the body’s natural barriers are other sexually transmitted infections (STI).”
However, it is less convincing when it turns to explaining the high prevalence in East and Southern Africa. This is the explanation offered: “HIV reaches very high levels only in areas where there are lots of simultaneous sexual partnerships, lots of untreated STIs and lots of uncircumcised men”(p. 134). It follows according to the argument that concurrent sexual partnerships helps to explain Africa’s high HIV prevalence. Why this explanation is not convincing? Take the case of Benin, in West Africa. Benin is a low HIV prevalence (1.5% ) country and therefore we would expect not to find factors that have put forth as driving the epidemic in Eastern and Southern Africa. Let’s have a look:
1. Simultaneous sexual partnerships: on the basis of anecdotal evidence (talk to anybody in Dassa-Zoume or Cotonou and they will tell you that) Benin is a country where polygamy or better polygyny (an husband with multiple wives)) is widespread. Similarly, marriages seems to follow pregnancy rather that preceding them thus signaling pre-marriage sex. Further, in this study of client of female sex workers in Cotonou two thirds of regular partners of female sex workers reported to have another regular sexual partner. Male sex partners form, according to the authors, a bridging population of HIV/STD transmission to and from female sex workers to the general population.
2. This situation is compounded by low condom use. This study for example shows that overall condom use was low at 34% (perceived efficacy and utilization-related problem were the main barriers to condom use). Similarly, according to the Demographic and Health Survey 2001 the condom use was as low as 14.6%
3. Circumcision appears to be only practiced by the Muslim minority
4. The other variable is untreated STIs and I could not find any study concerning this subject. However, since 1, 2, 3 in Benin are similar to those in Eastern Africa, the differentials in HIV prevalence could be explained by a difference in STIs treatment. This leaves the following questions unanswered: why Benin is more likely to treat STIs, if this is the case, as compared to Eastern or Southern African countries?
To sum up: Benin has a high level of concurrent sexual partnerships, low use of condoms and lots of uncircumcised men, and yet a low prevalence rate. Why? Are we missing something in our analysis? This bears also other questions: what is the role played by the transfusion of infected blood? Or the use of infected needles in clinics? Is it really the case that differentials in HIV rates between East and West Africa are explained by the treatment or lack thereof of STIs ? What is the role played by homosexual sex? And more importantly what do we know about it?