Friday, March 6, 2009

Senegal: an Exception Among HIV Epidemics in Africa?

After spending a lot of time studying as much HIV literature as I could find, I decided to chart the history of HIV in one country, Kenya. This decision stemmed from the belief that the conditions in a country prior to the arrival of HIV are as important as what a country does subsequently to deal with the epidemic. In fact, those conditions may be far more important than the subsequent measures taken to reduce the spread of HIV and certainly would determine a country’s ability to reduce the spread of HIV.

Many of the HIV prevention interventions carried out to date, throughout Africa, have had limited success. In Kenya, very little was done until early in the 2000s, by which time HIV prevalence was declining quickly as a result of a high death rate. Now that HIV prevention programmes have been around for long enough to carry out significant evaluations, it seems that a lot are not performing very well.

Since a lot of HIV funding was motivated by political, religious, moral and commercial considerations, it is not very surprising that so many of the programmes have been a failure. Of course, not all have been so motivated and not all have been a failure, but much of the money has clearly been wasted. 

The politics, the religion and the moral posturing continues. The commercial considerations, on the other hand, have changed radically. HIV is a massive opportunity for pharmaceutical companies. It has also been a godsend for suppliers of other goods and services, consultancies, private health and large, prominent NGOs such as Family Health International, Population Services International and others.

Senegal is often cited as an exception among African countries. HIV prevalence there remained at a very low rate for the whole of the nineties and, though it has been steadily increasing since, has probably never gone far above 1%.

It must be made clear, West Africa is quite different from East Africa (and, indeed North, South and Western Equatorial Africa, which all have identifiable 'regional' pandemics). The majority of countries in West Africa never had prevalence of above 2%. This compares with a high of 14% in Uganda and 11% in Kenya. In fact, the majority of East African countries currently have HIV prevalence rates of over 4%.

This is a relatively quick and dirty comparison of Senegal and Kenya as I am not in a position at the moment to do more detailed work on Senegal; but here goes!

Kenya made some advances in health, education, the economy and other social areas in the 1970s, the decade following independence. Their success began to level off in the 1980s, in part as a result of conditionalities and structural adjustment policies emanating from the International Monetary Fund (IMF) and the World Bank. By the 1990s, Kenya was on a downward trend that continues today. This downward trend is sometimes blamed on the effects of HIV but it started before HIV would have had much influence.

Senegal seems to have had a steady upward trend in social indicators from 1975 to 2005 and is on target to exceed Kenya's position. Senegal is still behind Kenya in some areas, such as education, but this may yet change. And Senegal is ahead in life expectancy, a significant health indicator.

The Human Development Index (HDI), produced by the United Nations Development Programme, is a composite measure of the level of development in a country. It combines measures "of life expectancy at birth, adult literacy and combined gross enrolment in primary, secondary and tertiary level education, and gross domestic product (GDP) per capita in Purchasing Power Parity US dollars (PPP US$)".

The graph, below, shows how Kenya and Senegal compare in their Gender Development Index (GDI), Life Expectancy (LE) Index, Education Index, Human Development Index (HDI) and Gross Domestic Product (GDP) Index.

The second graph shows Kenya's rise and fall and Senegal's steady rise in the Human Development Index.

With regard to the HDI, it is to be hoped that developing countries are doing just that, developing. That is not the case in Kenya. It has experienced retrogressive development since the 1980s and this trend, presumably, has roots in the 1970s and earlier. Senegal seems to be going in the right direction.

But the difference between Senegal and Kenya going by these five social indicators does not explain, on its own, why Kenya has had a serious and generalised epidemic and Senegal has not.

Senegal is said to have a concentrated epidemic, meaning that most of the people infected belong to high risk groups, such as commercial sex workers (CSW), men who have sex with men, intravenous drug users, haemophiliacs and perhaps others. Kenya's epidemic is classified as generalised because the majority of those infected now are not members of identifiably high risk groups. Members of high risk groups are infected but they are increasingly outnumbered by people who are not members of such groups.

My suspicion is that there is something about the conditions that existed in Senegal when HIV arrived that resulted in the epidemic not spreading beyond high risk groups. I think it was inevitable that Senegal would only experience a concentrated epidemic and equally, it was inevitable that Kenya would experience a generalised epidemic.

I have already discussed on this blog why I think it was inevitable that HIV would become generalised in Kenya. But, although I haven't had the chance to study Senegal in detail, there are several telling factors that could shed light on the matter.

John Iliffe, in The African AIDS Epidemic: a History, notes that commercial sex workers are licensed and inspected, following a French model. This contrasts sharply with the situation in Kenya, where sex workers are not an easily identifiable group, with some people resorting to transactional sex as and when they need to. But also, sex workers, and even those suspected of being sex workers, are treated as barely human. They are victims of abuse from the public, their clients and the police. Few, if any, of their rights are recognised by the law and they are obliged to accept this.

In Kenya, unlike in Senegal, there are few health services, health is not particularly accessible and it is especially inaccessible for those known to be or thought to be involved in commercial sex work. Iliffe notes that Senegal already had a successful programme to reduce sexually transmitted diseases, started in 1978, and their health services were able to control the blood supply, something Kenya and other countries are still struggling with.

There were other factors in Senegal that worked to its favour; male circumcision is almost universal; many Senegalese are Muslims and, consequently, have very different lifestyles from the predominantly Christian Kenyans (although the positive and negative effects of any religion can be mixed); HIV-2, a less virulent form of HIV (more correctly called HIV-1) was already common when HIV-1 arrived; condom use during casual sex was already very common in urban areas; and the country was quick to mobilise leadership, education, NGOs and various social services in reaction to the epidemic.

Travelling around Kenya and talking to people, it is clear that the government has done very little and will probably continue to do very little. Educators often know as much about sex as anyone else (and that's not much); they often shy from talking about sex and especially about condoms because of their religious or moral beliefs or because of those of their peers and those of parents; male attitudes towards females seem to have changed little; a lot of NGOs are carrying out pointless HIV 'prevention' activities because their donors would remove funding if they did anything else; other NGOs are doing a good job but are hampered by lack of money and support.

From what I have seen and read in Kenya, it is hard to believe that billions of dollars have been pumped into the country to contribute to the fight against HIV. At least since the 1980s, health, education, infrastructure and other social services have been run down, despite all the talk about achieving millennium development goals (MDGs) and fighting HIV. Most development indicators have been declining for thirty years.

Conditions in Kenya, I think, made it inevitable that HIV would spread rapidly and become generalised, almost from the beginning. The positive feedback from the epidemic would also fuel the already declining social trends. If Iliffe is right, conditions in Senegal were never such that HIV would spread beyond high risk groups and the country was in a position, and continues to be in a position, to protect people from dangers like HIV.

Kenya is not in this position and this explains their continuing predicament. It also explains why I think universal male circumcision, universal testing and treatment (UTT) pre-exposure prophylaxis (PrEP) or any other technical solution will have limited success. The country is weak and vulnerable. Thirty years of retrogressive development need to be reversed. Money needs to be spent on basic needs such as primary health, education, infrastructure, water supply and food security.

(For further discussion of PrEP, see my other blog,


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