AIDS and Development in Africa

A Social Science Perspective

R Dennis Shelby, Kempe Ronald Hope, Sr

• Publisher: Routledge
• Year: 1999
• Print ISBN: 9780789006387
• eBook ISBN: 9781136602191
• Topic: Medicine
• Subtopic: AIDS & HIV

AIDS and Development in Africa: A Social Science Perspective is the first book-length treatment of both the impact of AIDS in Africa and an assessment of intervention strategies in varying cultural situations. Developed from revised selected papers from the nineteenth Southern African Universities Social Science Conference, AIDS and Development in Africa will be of interest to counselors, medical and development practitioners, Africanists, and AIDS researchers. From this book, you will find wide analytical coverage of the issues and country case studies related to the contributory factors and development impact of the HIV/AIDS pandemic in Africa. You will also explore the ability of countries to willingly promote and cope with the pandemic in the context of their different economic circumstances.Specifically in AIDS and Development in Africa, you will read about:

• socioeconomic context of AIDS
• social scientific explanations of the AIDS pandemic in Africa
• HIV/AIDS and the status of women in Botswana and Swaziland
• sexual abuse and HIV/AIDS
• law and HIV/AIDS
• orphans of the AIDS pandemic
• media and the African context of social construction
• human resource development and training in relation to HIV/AIDS in ZambiaAIDS and Development in Africa uses a multidisciplinary social science perspective in case studies of such countries as Botswana, Swaziland, Zimbabwe, South Africa, Malawi, and Zambia to reveal contributory factors and the developmental impact of HIV/AIDS in Africa. This book demonstrates the human consequences of AIDS and the efforts being made by governments, individuals, families, villages, communities, and national government organizations to respond to the pandemic. For example, you will learn about information campaigns and peer education approaches that are successfully increasing transmission awareness and condom use. You will read beyond the usual analysis of demographics and receive much more substantial assessments and analyses of the burden on people, economies, and health care systems of the African countries. AIDS and Development in Africa is indispensable to anyone who is involved with HIV/AIDS prevention/intervention in Africa. This comprehensive book provides you with essential and up-to-date research on the many issues surrounding Africa's HIV/AIDS pandemic.

Chapter 1
The Socioeconomic Context of AIDS in Africa: A Review

Kempe Ronald Hope Sr.

Introduction

Acquired Immune Deficiency Syndrome (AIDS) is a fatal disease that strikes an adult, on average, five to ten years after being infected by the human immunodeficiency virus (HIV). Globally, the spread of HIV/AIDS continues to be rapid. In Africa, where HIV/AIDS is increasing at an alarming rate, at least one million persons are being infected annually and the projected numbers for the year 2000 are twenty million (UNECA, 1996). Within sub-Saharan Africa, HIV infection is unevenly distributed across geographical areas, age groups, and socioeconomic classes. The percentage of the population infected with HIV ranges from less than 1 percent across most of the continent to more than 25 to 30 percent in certain cities in eastern, southern, and central Africa (UNECA, 1996).

Infection rates among adults in many large African capital cities, and even in some rural areas, already exceed 25 percent and are expected to climb to this level in other cities over the next ten years. Because each 10 percent increase in the infection rate increases annual mortality by at least five per thousand, previously high levels of adult mortality are tripling and quadrupling in these areas (World Bank, 1991). It was estimated that by 1996 more than nine million people worldwide had died of AIDS. Of that total 7.6 million were in Africa (The Economist, 1996).

The AIDS pandemic is imposing and will continue to impose, in the foreseeable future, a significant and potentially crippling burden on the peoples, economies, and already inadequate health care systems of the African countries. It is a human and economic disaster of massive dimensions. Infections tend to strike adults in the prime of life, plus up to one-third of all children born to infected mothers. Babies born to women infected with HIV have a 20 to 40 percent chance of contracting the virus from their mothers. Almost all of these children die before the age of five. By the year 2000, the total number of infants born with HIV infection, in Africa alone, is expected to exceed one million, of whom more than 600,000 will likely develop AIDS (World Bank, 1993; UNDP, 1991).

Millions of children who are not infected with HIV are already suffering emotional and economic deprivation because their parents have died or are chronically ill. It is estimated that during the 1990s more than ten million children uninfected with HIV will be orphaned by AIDS (Panos Institute, 1992). In many parts of sub-Saharan Africa, the extended family system, which has traditionally absorbed orphans, will come under severe strain as parents die of AIDS, leaving aged grandparents to cope with large numbers of young children.

The rapid, increase of mortality due to AIDS in Africa has created a major public health crisis across the continent. AIDS is believed to be the leading cause of mortality between the ages of fifteen and thirty-nine in such countries as Botswana, Malawi, Uganda, and Zimbabwe (Brown, 1996). In sub-Saharan Africa, unlike other regions, the principal mode of transmission of HIV has been heterosexual intercourse. This has been so since the epidemic was first detected and such transmission now accounts for more than 80 percent of infections (Panos Institute, 1992). However, there is also substantial vertical (mother to child) transmission. The African AIDS pandemic is, accordingly, very much a family matter and has a major impact on all parts of society. Faced with this calamity, the major concern now for policymakers and. socioeconomic development planners is the overall socioeconomic impact that the AIDS pandemic will have on African countries. In other words, they must determine the long-term effects of AIDS on African population growth and other socioeconomic indicators and develop strategies to deal effectively with those effects (Hope, 1997).

Recently, some attempts have been made to help individual countries make some assessments. These attempts have concentrated on three primary issues. The first is the human costs of AIDS; the second is the social costs associated with the disease; the third is the economic impact of the disease. These are the issues addressed in this chapter. However, first it is necessary to examine those factors that influence the magnitude of the AIDS pandemic in Africa.

Factors Influencing the Impact of the AIDS Pandemic

The World Health Organization (WHO) and other researchers have identified several major trends within the African AIDS epidemic. It is concentrated primarily in eastern, central, and southern Africa, it is spread largely through heterosexual and perinatal transmission, and it most heavily affects adults of both sexes between the ages of fifteen and forty-four. Giving rise to those characteristics are certain economic, infrastructural, sociocultural, and political factors which, in turn, heavily influence the magnitude of the socioeconomic effects of AIDS in Africa.

Economic Factors

Without a doubt, poverty and economic distress in the African countries have contributed greatly to the rapid spread of the HIV and AIDS. Africa remains one of the poorest regions of the world. Low levels of education, crowded and unsanitary living conditions, malnutrition, limited access to basic services, high rates of unemployment, and rapid urbanization are all poverty phenomena that are increasingly associated with HIV/AIDS. Poor people who contract HIV, moreover, tend to develop AIDS much faster than individuals of a higher socioeconomic status (Storck and Brown, 1992; Hope, 1995).

Limited employment opportunities in rural areas have contributed. to rural-urban migration which, in turn, has increased the urbanization of poverty where cities lack the capacity to absorb the rural poor (Hope, 1997). Furthermore, some of the social and economic conditions associated with urban living tend to encourage behavioral patterns such as drug abuse and prostitution, which increase the risk of being infected with the HIV/AIDS. In addition to rural-urban migration, there is also the problem of cross-border migration. Migrants are a very high-risk group. They are primarily single men who suffer loneliness. They also have the potential for spreading the virus when they return home. Single women who migrate may also be forced into sexual activity as a survival mechanism (Whiteside, 1993a).

The circulatory nature of most population movements in Africa implies that two points, both the destination and the origin areas, are at risk of outbreak because a migrant may transmit the disease. The high ratio of males to females at migration destinations implies that females are in demand for casual sexual relations, hence the persistence of promiscuity and prostitution in the urban areas which, in turn, increases the HIV transmission rate (Anarfi, 1993). In Ghana, Gambia, Uganda, Zambia, and Tanzania, for example, cross-border migration has been blamed for a very large proportion of the known cases of AIDS (Anarfi, 1993).

Generally, the health consequences of poverty are very severe (World Bank, 1993). The poor die younger and suffer more from illness and disability. In Africa, poverty contributes to the heterosexual spread of AIDS most frequently through situations in which relatively few women (usually commercial sex workers) have sexual contact with large numbers of men (Caldwell, Caldwell, and Quiggin, 1989; Orubuloye, Caldwell, and Caldwell, 1994). Thus, work-related, migratory, and other forms of economically based variations in sexual behavior determine to some extent the existing pattern of the AIDS epidemic in different parts of Africa. For example, HIV might also be spread through temporary residents or transient workers such as soldiers, tradespeople, and truck drivers.

Commercial sex workers, because of their large number of sexual partners, are a group most at risk for HIV infection in many African countries. Unfortunately, in many African cities, this risk has resulted in infection levels approaching 50 percent. In some of these cities, and especially among the poorer prostitutes (who tend to have more clients), infection has become nearly universal (Way and Stanecki, 1994). For example, in Abidjan, Côte d'Ivoire, seroprevalence among commercial sex workers rose from 69 percent in 1990 to 86 percent in 1992-1993 (Way and Stanecki, 1994). In Nairobi, Kenya and Kigali, Rwanda commercial sex workers have rates of seropositivity reaching around 90 percent (Fleming, 1993).

Infrastructural Factors

Economic distress in Africa means that countries in the region face increasing pressure for the allocation of scarce resources. Those resources have been declining in their budgetary allocations for infrastructure, including health care. Data for the period 1985-1995 indicate that the sub-Saharan population with access to health services stands at 57 percent compared to 80 percent for all developing countries, the population per doctor is 18,488 compared to 5,767 for all developing countries, and public expenditure on health is 2.4 percent of GDP compared to 2.0 percent in all developing countries (UNDP, 1996).

The countries of sub-Saharan Africa also have the lowest ratio of hospital beds to population. There are eight to ten times fewer hospital beds than the average for Europe, and beds are even much more scarce in rural areas (Cabral, 1993). This places considerable strain on the medical staffs in their allocation of hospital beds given the increasing number of patients with AIDS. As many as 30 percent of inpatient beds in hospitals in Uganda, Malawi, and Zaire are occupied by HIV-infected patients (Cabral, 1993; Armstrong, 1995). In Addis Ababa, Ethiopia, AIDS patients fill 80 percent of the hospital beds (Kelso, 1994).

Given the special care that AIDS patients require and their greater average length of hospital stay compared to most other patients, there is bound to be increased demand on already scarce hospital resources. Moreover, the medical staffs find themselves with less time to devote to non-HIV patients who may, in turn, find themselves less likely to recover than would otherwise be the case.

In addition to the health care infrastructure, there are also problems with the infrastructure for education and information communication. In many African countries the education infrastructure is in a state of decrepitude and access to information is almost nonexistent, especially for rural dwellers. Fortunately, however, some international and regional nongovernmental organizations (NGOs) have recognized this problem and have begun to implement education and information programs in many African countries at the grassroots level as a vital intervention measure. Some of these organizations are now being ably assisted and funded by WHO, UNAIDS, and other international organizations and donor countries.

Sociocultural Factors

Some sociocultural traditions and practices that are unique to Africa have a major impact on the transmission of HIV/AIDS in the region. These traditions and practices relate primarily to what is known in the literature as sexual networking (relations with multiple sexual partners).

In many African countries, it is not unusual for women to have transactional sex outside of marriage. This is not frowned upon since the control of female sexuality is often akin to the control of property. In sub-Saharan Africa, there are also high rates of polygyny partly because farming and economic strength depend solely on the size of the workforce. The polygynous system has serious implications for the spread of the AIDS epidemic since entire families may find themselves victims of the disease through polygynous association (Caldwell et al., 1993).

In Africa, 30 to 50 percent of married women are currently in polygynous marriages and nearly all wives must be emotionally and economically adjusted to the possibility of finding themselves in a polygynous marriage at any time. This means that African women are aware that the greatest danger comes from their spouses, and it is most likely that the majority of female AIDS victims have been infected by their husbands (Caldwell et al., 1993).

Another sociocultural tradition with implications for the AIDS epidemic is called "wife inheritance." Practiced in some parts of Africa, wife inheritance is highly valued by most women for the economic and social security it provides them and their children. The tradition demands that if a woman is widowed, she must be inherited either by a younger brother-in-law, or by an older stepson in some cases, in order to safeguard the property of the deceased for his children. This also ensures that future children stay within his clan. However, in this new union either partner may infect the other and thereby increase the spread of AIDS.

In addition to wife inheritance, in some African countries such as Zambia, there is also the ritual practice of "sexual cleansing." This practice requires the surviving spouse to have sexual intercourse with a chosen member of the family of the deceased. In the case of a deceased man, the relative is usually a nephew (on the maternal side), a grandson, a brother, or a grandfather figure. In the case of a deceased woman, they would choose a niece (brother's daughter), a granddaughter, or grandmother by relationship such as the sister of a grandmother. Sexual cleansing is regarded in some areas as an important tradition and an effective way of freeing the surviving spouse from the ghost of the deceased, it is believed that the spirit of the deceased lingers on and the widow or widower would therefore not be free to get on with life until this ritual is over. For a widow, the period required for freedom depends on how good or bad, in the eyes of the in-laws, she has been while her husband was alive. Undoubtedly, the practice of sexual cleansing has the potential to significantly increase the spread of HIV and AIDS.

The final example of sociocultural traditions and practices with implications for the AIDS pandemic in Africa relates to male circumcision. Some of the recent research on this issue suggests that there is a direct link between the practice of circumcision itself and the incidence of disease; more specifically, the lack of circumcision predisposes men to sexually transmitted diseases (STDs) and possibly now directly to AIDS (Caldwell and Caldwell, 1994). Moses et al. (1995), for example, found that where male circumcision is practiced, HIV seroprevalence was considerably lower than in areas where it is not practiced. Consequently, the lack of circumcision in males is a risk factor for HIV transmission and some emphasis should now be placed on cautiously searching for acceptable interventions in this area (Mertens and Carael, 1995).

Political Factors

In most African countries there is considerable distrust of politicians and governments by the citizenry, and perhaps for good reasons. Two salient features of the politics of sub-Saharan Africa, for most of the period since independence, have been the persistence of highly personalized authoritarian rule and the rampant spread ...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Contents
• About the Editor
• Contributors
• Preface
• Chapter 1. The Socioeconomic Context of AIDS in Africa: A Review
• Chapter 2. Social Science Explanations of the AIDS Pandemic in Africa
• Chapter 3. Beyond the Statistics: HIV/AIDS As a Socioeconomic Epidemic in Africa
• Chapter 4. HIV/AIDS and the Status of Women in Botswana
• Chapter 5. Women's Health, Sociocultural Practices, and HIV/AIDS in Swaziland
• Chapter 6. Sexual Abuse, HIV/AIDS, and the Legal Rights of Women in Swaziland
• Chapter 7. The Law and the HIV/AIDS Epidemic: Competing Claims and Interests
• Chapter 8. Orphans of the AIDS Pandemic: The Sub-Saharan Africa Experience
• Chapter 9. Media and the African Context of the Social Construction of HIV/AIDS
• Chapter 10. The Social Context of HIV/AIDS Policy in Africa
• Chapter 11. A Note on National Policy and HIV/AIDS in Zimbabwe
• Chapter 12. Societal Responses to HIV/AIDS in Botswana
• Chapter 13. AIDS Awareness and Sexual Behavior Change in South Africa
• Chapter 14. HIV/AIDS and a Return to Traditional Cultural Practices in Malawi
• Chapter 15. The Question of Relevance in AIDS Education in Malawi
• Chapter 16. AIDS and Peer Education in Lesotho
• Chapter 17. Human Resource Development and Training in Relation to HIV/AIDS in the Formal Sector in Zambia
• Chapter 18. HIV/AIDS, Households, and the Informal Economy in Africa: An Endnote from the Field
• Index