HIV: What's Different About Africa if it's Not Down to Sex?

In an article about HIV in Botswana, Ntibinyane Ntib remarks on something I have always found hard to understand about the virus in high prevalence African countries; the issue of families and of several members of the same family being infected with HIV. Of course, in Botswana, several members of many families must be infected, given prevalence figures of 25% nationally and far higher rates in certain groups and geographical areas. But how were they infected? Sexual behavior between different African and non-African countries, and indeed within African countries, doesn't vary that much. And differences have never clearly been correlated with HIV prevalence. Or rather, some people in all countries, Africa and elsewhere, have a lot of sex, most don't have a lot and some have none at all.

If you swallow the orthodoxy about African sexuality and various other bigoted views, it wouldn't be so surprising that HIV 'runs in families'. About 10 years ago I saw a brief play in Western Kenya purporting to be about the spread of HIV through illicit sex, as well as to a small extent through licit sex. The father slept around and became infected, he went on to infect his wife and the housegirl, his wife was pregnant, the implication being that the baby would be infected, and to cap it all, their teenage son was also sleeping with the housegirl. It's no wonder Kenya was getting a lot of HIV money while the pickings were rich, they certainly pushed all the right buttons.

But outside of African countries, and it's only some African countries where HIV prevalence is very high, HIV does not 'run in families'. It primarily infects men who have sex with men and intravenous drug users. So what is different about Africa? Well, a lot of surveys show that HIV is not always transmitted sexually. Babies are infected whose mothers are uninfected, many virgins have been infected and many people who only have one uninfected sexual partner are infected. What we don't know is the extent of non-sexual transmission. But we do know that heterosexual transmission cannot be entirely responsible for extraordinarily high prevalence rates found in countries like Botswana.

In a blog post on the Don't Get Stuck With HIV site, David Gisselquist goes into more details. About 10 years ago, an initiative called the International Network of Religious Leaders living with or Affected by HIV/AIDS (INERELA+) came up with an alternative to the ubiquitous but wholly ineffective ABC strategy (Abstain, Be faithful and use Condoms). INERELA+'s strategy is called SAVE, which stands for: Safe sexual and skin-piercing behavior; Access to treatment; Voluntary counseling and testing; and Empowerment. Gisselquist goes on to outline a two ways of using SAVE to reduce HIV transmission by as much as 45%. This would involve existing programs for preventing mother to child transmission and couple counselling, both of which would need to be stepped up.

The author of the article on Botswana makes the point that the country is relatively rich, as if HIV should never have spread so rapidly there. Well, HIV is highest in several relatively rich  African countries, Botswana is not the only one. HIV is also high in countries that have (or had) high rates of formal employment compared to a lot of other countries on the continent. These high prevalence countries also tend to have good infrastructure, accessible health services and even relatively high educational standards. Even within medium and high prevalence countries, it is often the richer and better educated people who are most likely to be infected with HIV.

Proponents of the sex theory (if it could be called a theory) of HIV argue that wealthier and better educated people are more mobile and have more sexual partners, or bigger 'sexual networks', etc. They also studiously ignore the non-sexual risks that wealthier people may have, such as access to health services. But access to health services is not enough to reduce HIV transmission, those health services must be safe. Diamond miners in Botswana, it has often been remarked, suffer high HIV rates. But they don't just have more money that they can spend on 'illicit sex', they also have access to health services. Are these health services safe?

The Botswana article also describes sick people in ways that suggest it was not always known what a person was suffering from or what they died from. What the author describes, in fact, could be something other than HIV, such as TB, some other disease or several diseases. Were all these people just assumed to be suffering from and dying from HIV? Large scale extractive industries have an appalling corporate social responsibility record, especially in Africa. Could many people in Botswana have been infected with TB though their work in mines or through contact with TB infected people? TB doesn't just infect people with HIV, it also increases susceptibility to HIV infection and increases the chances of transmitting HIV. And while it's hard to see why HIV should 'run in families', it's not at all hard to see why TB should.

There are several things that are different in Africa when it comes to inordinately high HIV prevalence rates, and sex is probably not one of them, or not one of the most important. Unsafe healthcare, high disease burden, risky living conditions and working conditions look like fruitful areas for inquiry. The author is right to worry about cuts in funding for antiretroviral treatment and I hope this is addressed. However, Botswana needs to give HIV prevention a lot more attention and sex a lot less attention. There's a something wrong in a country where one quarter of the adult population is infected with a virus that is hard to transmit sexually; it may be that the virus is being transmitted non-sexually.

[For more about non-sexual HIV transmission and male circumcision, see the Don't Get Stuck With HIV site.]