The urgency of fight against AIDS in Africa

Madeleine Bunting, Guardian News Service, London

Since Hiv/Aids was first diagnosed nearly 25 years ago, more money has been put into combating this disease than probably any other in human history. It's not hard to see why: No other disease has ever threatened such a devastating impact as it attacks the generation whose labor and child-rearing is pivotal to the functioning of any human society. But the latest figures from UNAids ahead of World Aids Day on Thursday show that despite the billions of dollars (perhaps US$22 billion since the 1980s), prevalence in most of southern Africa is still rising -- Swaziland has now crossed the 40 percent mark, while Botswana, at 37 percent, is heading that way, and South Africa is close to 30 percent.

So just why has Africa been hit so hard? And why has all the money invested in prevention programs had so little success in Africa (apart from the striking and oft-cited exception of Uganda)? Part of the answer to both questions was offered by 30- year-old Josina, in a clinic in Maputo, the capital of Mozambique, earlier this month.

She looked younger than her age despite being HIV-positive and having three children and another on the way. Dressed in a halter- neck T-shirt dress and woolly hat, she shyly explained her position. Twice, she'd had boyfriends but they left her when she got pregnant, she now had a boyfriend, but he was in prison so she had found another boyfriend who had offered to help get him out. What she described was a network of relationships, sometimes overlapping, on which she relied to feed her children. Often she ended up abandoned or betrayed.

There are two characteristics to Josina's painful story which are replicated across Africa. Firstly, what's known as "concurrence". Research indicates that the number of sexual partners in Africa and the west is broadly similar, the difference is that across Africa, many men and some women have two, three or more long-term relationships at the same time, whereas in the west, the dominant pattern is of serial monogamy -- one at a time with the occasional one-off.

The problem is that concurrence is uniquely susceptible to spreading HIV/Aids; transmission is more likely to happen in ongoing sexual relationships than in one-off encounters, and once one person is infected, they will infect the whole network.

Secondly, concurrence is reinforced by inequality. In a country with high levels of poverty -- in Mozambique nearly 80 percent live off less than a pound a day -- the deal offered by a truck driver or street vendor with some Mozambican meticals in his pocket can represent the best survival strategy for a woman.

This is a disease that is feeding off desperate poverty. If you're worried about where your child's next meal is coming from, or how you are going to avoid being thrown out of your shack for not paying rent, longer-term risks such as dying of Aids carry little weight.

The plight of Josina and the millions like her is central to the battles that have been waged among experts for more than a decade. The hope was that prevention was simply a matter of making Josina aware of the risks she is taking; information and free condoms would be enough to induce behavior change.

But in many places it hasn't worked; Botswana has been swamped in condoms, but they've had little appreciable effect, as Helen Epstein, a molecular biologist at America's Princeton University, points out. Women are rarely in a strong enough position to negotiate condom use, men are often very resistant to using them, and besides, without a rubbish collection system, where do you put the used ones?

Those advocating behavior change still dominate American policy on Aids, and the U.S. -- the biggest donor to HIV/Aids programs in Africa -- wields huge influence as to how the world sees this disease and how it should respond. Key to that influence since the 1980s has been how Aids emerged in the U.S. gay community as an issue about individual human rights. That made it easy, after the arrival of Bush in the White House, for the religious right to graft on its own agenda about individual morality.

U.S. programs now emphasize "abstinence until marriage". "Chance would be a fine thing" is how one might imagine Josina retorting. In interviews women often describe seductions that they believed would lead to marriage, but didn't. This is not about commitment-phobes, but about poverty; marriage rates have plunged in southern Africa since the 1970s, partly because young men cannot afford the lobola, or bride price, required in cattle.

The anger among experts is that America's neuroses about its own sexual mores are being projected on to Africa's crisis. Prof. Tony Barnett, of the London School of Economics, argues that it is absurd to focus on how people behave without understanding the economic and social context that drives behavior; is Josina's quest for boyfriends a sign of promiscuity, or a rational response to desperate times?

In his book Aids in the Twenty-First Century, Prof. Barnett charts how the old social structures of village and region have been disrupted, often violently, over the past century. Migrant labor for the mines, truckers along import/export routes, the movement of armies, urbanization: All have facilitated the spread of HIV/Aids.

Patterns of status and authority and accepted norms of heterosexual relationships all unraveled; that left women particularly exposed and made intimacy an arena for confusion, often betrayal and now disease. HIV/Aids has been the savage by- product of Africa's experience of globalization.

HIV/Aids is both a cause and a consequence of the continent's poverty, and it threatens to lock some of the worst-affected countries into a vicious downward spiral. Steel yourself, the worst is still to come: In 10 years those infected today will be very sick, dying or in a desperate search for antiretrovirals.

How does 40 percent of a country die? What kind of societies do you have when children bring up children? It is these kinds of nightmare scenarios that are galvanizing the global effort to scale up antiretroviral treatment. Complex drug regimes developed in the west are being pared down to the most rudimentary level to be rolled out for millions of people.

African governments will need help to build clinics, find nurses and train doctors -- to build up a healthcare system, in many places from scratch. The scale of the challenge is daunting.

And the challenge here in the west is no less so. How do you engage people in this crisis to commit to the long term? This year's Make Poverty History/Live8 campaign claimed that what was needed was "your voice, not your money". It's not true; both are needed. And we're not talking about a one-off cheque.

What this disease requires of us is an unprecedented level of ongoing commitment and ethical imagination. Think of it as the first global tax: Each of us pays for one person's drugs. For the rest of our lifetime, Africans will be struggling with this catastrophe. We can't leave them to it.