HIV/AIDS: A Crisis in Africa

In 1991, one of the best basketball players in the world - "Magic" Johnson - announced that he was HIV positive. Because he is a famous athlete, Johnson brought a lot of attention to HIV/AIDS, especially in the United States. Johnson drew attention to the fact that HIV/AIDS is a disease anyone can get, no matter how important or how wealthy a person may be. Along with Johnson, other famous people have spoken out about HIV/AIDS. On December 1, World AIDS Day, concerts and speeches are held all over the world raising money to fight HIV/AIDS and informing people about it too. Many people, because of Johnson and other celebrities, have heard about HIV/AIDS, but still many do not know a lot about how it is affecting people all over the world.

Why should people know about HIV/AIDS?
Every country in the world has been affected by HIV/AIDS. As of 2015, there are over 36 million people in the world living with HIV/AIDS. That's almost 400 football stadiums full of people. In 2015, an estimated 1.1 million people died from the disease -that's over 3,000 people a day. Scientists also say that the number of people with HIV/AIDS is growing, not shrinking, meaning that for the immediate future there will continue to be more and more people living with HIV/AIDS. It also means that there will continue to be more and more friends and family members who will lose loved ones to the disease. The number of HIV/AIDS related deaths have declined since the peak of the epidemic in 2005, due in part to antiretroviral treatment (ART) scale-up. However, HIV still remains a leading cause of death worldwide, and the number one cause of death in Africa.

You have undoubtedly heard of the term epidemic, referring to a disease that spreads rapidly within a region or country. This term does not reflect the severity of HIV/AIDS. Since HIV/AIDS impacts so many people in every region of the world, medical scientists refer to the disease as a pandemic.

Education is an important component of preventing the spread of HIV/AIDS.

How are HIV/AIDS and Africa connected?
Almost 70% of the 36 million people with HIV/AIDS live in Africa -that's roughly 25 million people - making Africa the epicenter of the disease. In addition, sub-Saharan Africa is the only place in the world where the number of women infected is higher than the number of men with HIV/AIDS.

Adult HIV Prevelance

HIV/AIDS and Orphans
Imagine that your parents have both just died of a disease that most people are too embarrassed to even say out loud. You may even have the disease yourself, but you don't know for sure. In fact, no one can be sure if you have it, so people point and whisper about your family behind your back. You and your sisters and brothers are taken from your house and split up among relatives and family friends from different cities, who may even be caring for other orphans. Once you arrive at your new home, you find out that there is little money for your schooling, clothes, or food.

The death of a child's parents is one of the most terrible situations a child can go through. HIV/AIDS, just in Africa, has made over 11 million children AIDS orphans (children under the age of 15 who have lost one or both parents to HIV/AIDS). Relatives have usually cared for orphans in Africa, as in many other places too, but HIV/AIDS has made that arrangement difficult. There have been so many deaths of adults, that there are fewer and fewer relatives to take care of more and more children. Many single women, grandparents, and even children are in charge of themselves and other AIDS orphans.

In many places, HIV/AIDS has a stigma attached to it. Because some people are embarrassed to talk about HIV/AIDS, they discriminate against people they think have the disease - whether they do or not. Sometimes, if a child loses his or her parents to the disease, people do not want anything to do with the child because they might have HIV/AIDS too. Not all people, though, discriminate against those with HIV/AIDS.

Some families that take in orphans do not have the money needed to take care of them. Families that take in orphans may not have enough money for them to go to the doctor. They also may not have enough money to feed them or give them clothes. In fact, orphans are more likely to be malnourished than non-orphans. The biggest expense for children, however, is school fees. Because many families cannot cover the cost, more and more children cannot attend school after their parents' deaths. In the U.S., Canada and Europe education is free; this is not the case in most African countries where governments don’t have sufficient money to provide totally free education to all children. Consequently, parents or guardians have to pay school fees for each child who attends school (see more below).

In some cases, there is not a relative to take in an orphan, so some children become homeless. Called "street children," they are forced to survive and find food on their own without a family or a home.

HIV/AIDS not only infects, but also affects people your age. It might difficult to think about how, as a child, you would live by yourself or only with other children. How would your future look? Could you stay in school? If you needed money, what jobs could you get? How would you take care of yourself? Because HIV/AIDS is a pandemic, it is important to know as much as we can about it in order to better understand how, through our governments and relief organizations, we can contribute to a solution so no child has to think of a future without his or her family.

HIV/AIDS and Risk
95% of all the people who have HIV/AIDS live in a developing country. If HIV/AIDS can infect anyone, no matter man or woman, black, white, Hispanic, or Asian, rich or poor - why are there so many more cases in developing countries? And, in sub-Saharan Africa, particularly among women?

Scientists continue to look for HIV/AIDS vaccines as well as for a cure. Researchers, though, from other disciplines besides "science", like anthropologists, political scientists, economists, sociologists, and others, also study HIV/AIDS and are looking for ways to stop the epidemic.

All groups, however, study theories about what puts people at risk for getting HIV/AIDS and why there are so many people in Africa with it. Risk is the idea that certain things make a person more likely to get sick, but do not mean that the person will necessarily get sick. For example, sharing a water bottle with someone who has a cold puts you at risk for getting a cold, but does not guarantee that you will get one.

What can we learn from other subjects, besides science, about why so many people in Africa have HIV/AIDS?

Social Context Approach
Other researchers, like anthropologists, political scientists, economists, and sociologists sometimes look at the social context of a place to study disease. The social context, or social environment, of a particular place helps determine how people make choices about their lives. For example, in places were most people live in poverty they may be forced to resort to activities that are illegal (like stealing) or un-healthy and unsafe (like selling drugs) in order to survive. We’re going to look at five ways in which social context impacts the spread of HIV/AIDS.

1.) Economics and Politics
Governments and economics play important roles in determining how people live. In the 1980s, many governments in Sub-Saharan Africa had to agree to Structural Adjustment Policies (SAPs) in order to take out loans from the World Bank and the International Monetary Fund [For more information on the impacts of SAPs and globalization on Africa, see Module Nine: African Economies (Activity Six)]. One of the agreements of the SAPs was to establish “user fees” for health clinics. The amount of these “user fees” was often too much for families to pay, so they could not afford to go to doctors. As more and more stopped going to clinics, doctors and nurses left Africa for countries that could pay them better. Even if they could afford it, the majority of people in Africa are not close to a health clinic (more than an 8 hour walk sometimes). Between 1990 and 1995, only 40% of all the people in Sub-Saharan Africa had access to a health clinic or a doctor.

You probably wonder why a continent as rich in natural and human resources as Africa is, has so much poverty. The answer to this question is too complex to provide a complete answer. We attempt to address this issue in the Exploring Africa curriculum, specifically in Module Nine: African Economies. Part of the answer lies in the economic policies and practices of colonialism. During the colonial period (roughly 1890 – 1960) the European colonial powers instituted economic practices that were aimed at extracting mineral and agricultural wealth from Africa with little consideration to the development of the colonies.

The colonial regimes depended on cheap labor to extract mineral and agricultural resources. In some parts of Africa, the colonial governments forced adult men of working age to leave their families and communities in order to work in mines and on large plantation- like farms. The forced migration of male labor was quite harmful to the migrant workers and to their families and communities. Many families became poorer because they lost the labor of fathers, husbands, and adult sons. Just as import, family structures were often weakened by the long-term absence of fathers, husbands and adult sons.

What does this have to do with the HIV/AIDS pandemic? A great deal! Although HIV/AIDS infects rich and poor alike, it is most prominent in areas of poverty and where traditional social and family structures have been negatively impacted by economic and social practices that were established during the colonial era. Indeed the countries in Southern and Eastern Africa that have been most impacted by the HIV/AIDS pandemics are the countries where colonial economic policies and practices resulted in large-scale labor migration and the impoverishment of rural communities and the townships were migrant workers live.

In 2015, to take one contemporary example, the average income for a Tanzanian adult was $6,881 (compared with $55,775 in the United States). Because jobs and money are so scarce in many places in Africa, people, mostly men, travel far from home in search of work. Many men become truck drivers or miners, moving to different countries for work. These men usually only come home once, maybe twice a year, to visit their families, wives, and children. During the rest of the year, though, they work and send money home. Because they are away from home for most of the year, many people develop sexual relationships with others who live in the same town. People must move where they can find jobs, so men and women may work in many places. Over time, they may have many “boyfriends” or “girlfriends”.

Having many boyfriends or girlfriends does not necessarily mean that someone will get HIV/AIDS, but it increases the risk that someone will become infected. Not having adequate health care also does not mean that someone will get HIV/AIDS, but it increases the chances that someone will not know they are infected or that they will not get the medicine that they need.

2.) Health Care
While HIV/AIDS has no cure, the best treatments for it are drugs called ART  (anti-retrobiral treatment). Magic Johnson has now lived over 2 decades with HIV on HAART (highly active anti-retroviral treatment). ARTs, though, are expensive - it can cost up to $36,000 a year for the treatment of one individual. The average per capita income, though, for most African countries is less than $800 a year - making the drugs too expensive for many people. For example, HAART drugs are so expensive because they protected by intellectual property rights, which are recognized by international trade laws. There are many organizations, governments, and individuals fighting to end intellectual property rights for HAART so that HAART can be made more cheaply and given to more people. It has only been in the latter part of 2003 that the U.S. government, the EU (European Union), and major drug companies have agreed to lift the patent rights allowing drug companies in Africa, Asia, and Latin America to manufacture generic versions of the HAART drugs. These agreements should have dramatically reduced the costs of drugs in Africa and other developing regions of the world, yet drug prices are actually rising.

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In South Africa, where there are 52.98 million people, 12% of people have HIV/AIDS. Up until 2003, President Thabo Mbeki claimed that the drugs did not work or that they caused too many bad side effects. He had even claimed that a virus does not cause HIV. Mbeki also refused to give HIV positive pregnant women a drug that prevents HIV transmission to unborn children. Rather President Mbeki claimed the AIDS epidemic was caused by poverty. Some people in South Africa thought their president was right, but others fought against him and even took the government to court so that drugs could be made available. At the end of 2003, the South African government promised five years of free HIV/AIDS drugs to all the people that need them. It would take years, though, for the drugs to get to everyone. in 2006, the process was impeded once again by President Mbeki, The prime minister advocated, instead of drugs, a diet of garlic, olive oil, and lemon as a cure for the disease. Until 2015, here was a ban in South Africa that prevented pharmacies from even selling HIV testing kits.

As you read through these materials you should think about the relationship between poverty and HIV/AIDS. While HIV/AIDS infects people regardless their wealth (remember Magic Johnson) are poor people more susceptible to the virus than people who have more choices due to their income and economic resources available to them?

Basic health care is also critical for people with HIV/AIDS. Because they have depressed immune systems, people with HIV/AIDS are more likely to get opportunistic infections, like tuberculosis and thrush. These opportunistic infections are not life-threatening if a person has a healthy immune system and the proper medicine, but people with HIV/AIDS do not have healthy immune systems and many people in Africa cannot get or afford appropriate medicine.

3.) Nutrition and Food Security
One of the most important areas that has been affected by HIV/AIDS, but is often not talked about is nutrition and food security. HIV/AIDS affects nutrition in three ways:

A.) Decreasing families' abilities to produce or buy food
In Sub-Saharan Africa, 80 percent of the population depends on small-scale farms for its food. In the last twenty years, over 7 million agricultural workers have died because of HIV/AIDS. Infection levels are highest among 15-49 year olds, which is the same age group that does most of the food production. As more and more workers become sick, farming becomes too difficult to do. As a result, many people are switching to crops that require less work, like cassava. The problem, though, is that crops like cassava, that require less work to grow, also have less nutrients in them, meaning that they are less healthy to eat.

In a household where there is someone with HIV/AIDS, there is 40% less food eaten because people cannot either grow or buy as much food as they had before someone got sick. Some people cannot grow food at all because they are taking care of relatives with HIV/AIDS, are too sick themselves, or cannot afford workers to farm for them. Other families are forced to sell their furniture and other possessions so that they can buy food and medicines for sick relatives. Sadly, many farmers are dying without teaching others how to grow food, so food insecurity will continue.

B.) Increasing malnutrition rates
Good nutrition is important for people with HIV/AIDS. While it cannot cure the disease, it can help people live longer and more comfortably. HIV/AIDS decreases metabolism and the amount of nutrients that the body can absorb, so organs, muscles, and tissues waste away more quickly. Good nutrition also keeps the immune system healthy so that the body can fight opportunistic infections.

It is also important to remember that the decrease in food consumption and that change in diet (to foods like cassava) also affect people who are not infected. As other family and community members eat less nutrients, they become malnourished as well and less able to care for sick relatives or able to work on their own.

C.) Decreasing positive effects of ART
Good nutrition also helps ART to work. In order to be most effective, a person on ART needs twice the amount of nutrients a normal, healthy individual needs. Good nutrition decreases the amount of side effects and strengthens the immune system. Unfortunately, many people in Africa do not have enough food.

4.) Education
An education is an important asset for everyone. Education provides skills necessary to make a living in today’s world, trains people for careers, prepares them to run governments, and teaches them how to solve problems. HIV/AIDS, however, is affecting the education system in Africa. In Zambia, for instance, thirty percent of the all the teachers in the country are living with HIV/AIDS. When they get ill, they have to take time off, which means there is no school for many children. In addition, there are not enough new teachers to replace teachers that get too sick or die from HIV/AIDS, which means some children will not have an opportunity to go to school. In Central African Republic, over 70,000 children under age 12 will not go to school because there are no teachers to teach them.

Along with the teacher shortage, there are also decreasing numbers of students. Many families cannot afford school fees, so their children cannot go to school. Also, many children are pulled from school to help care for sick relatives with HIV/AIDS or to help their parents work. Because their families need their labor, more and more children do not attend school.

What is important for the rest of the world to think about is that HIV/AIDS will have a long-term effect on Africa, even for people who are not infected. Even if a cure is found, generations of children will not have received the education they will need to get jobs, run their countries, or to take care of themselves when they become adults.

5.) Gender
Right now, Sub-Saharan Africa is the only place in the world where there are more women infected than men with HIV/AIDS. Why are women so vulnerable to this disease? Using the social context approach, we’re going to look at HIV/AIDS risk for women.

In 1979, the United Nations adopted CEDAW, or Convention on the Elimination of all forms of Discrimination Against Women. Over 174 countries adopted it, including many African countries. The goal of CEDAW was to ensure that women have the same rights as men in any country. Despite CEDAW and African constitutions that guarantee equal rights for men and women, many women are still treated as second-class citizens, without rights. Many people still follow customary laws in Africa. Customary laws are unwritten laws that certain groups of people follow that have been passed down through generations. There are different customary laws for every group of people, but many favor men and men’s rights over women and their rights. The lack of rights creates a special HIV/AIDS risk for women.

Land Inheritance and Food Security
One of the most obvious forms of discrimination against women is land inheritance. Most of Africa has a system of patrilinealism (in some parts, though, there are systems of matrilinealism). Because of patrilinealism, the land a husband and wife lives on belongs to the husband’s family. If he dies, his family can take the land back and force the widow out of the house and off the land, and possibly the children as well. Even if a woman goes to the police, the police may back her husband as they follow customary law as well.

Without land, a person has no way to grow food to eat or to sell to get money. Remember that 70% of people in Sub-Saharan Africa live in rural areas, not cities. Taking away land impoverishes a person immediately.

Education costs money. In families that have been affected by HIV/AIDS, there is even less money. In addition, there is a need for more people to care for the sick. Girls are the first family members pulled from school when a family is dealing with HIV/AIDS. Girls, then, can care for sick family members or work as maids to earn money for the family. In certain instances, a girl may be married so that her family can collect bridewealth.

The long-term effect of forcing girls to quit school is that they grow up without an education. Without an education, it is difficult to obtain a well-paying job. Without a well-paying job, girls become women who must rely on others then to help support them and their children.

Survival Sex Work
Survival sex work is the term given to women who sell sex in return for money or food. Researchers who study Africa use the term “survival sex work” instead of “prostitution” because without the income, women and their children would not have any income. In addition, many women do not see themselves as prostitutes, but as “friends” of particular men.

We’ve seen how women can be forced out of their homes, off their land, and how they are most likely to grow up without an education. If they have to feed themselves and their children, it leaves women with few options for work. Unfortunately sex work, in spite of its risks for HIV/AIDS, does not pay much. In South Africa, some women make less than $2 per encounter, ensuring that women must have multiple partners in order to have enough money to feed their families.

Condoms are one of the most popular methods of preventing pregnancy and sexually transmitted diseases. Yet, they are not used enough to slow the spread of HIV/AIDS in Africa – why?

Condoms have a social context too. Because men often have more power in relationships than women, they are usually the ones who decide if a condom can be used during sex. In many places in Africa, men refuse to wear condoms because they think condoms are not needed. In justifying their decision not to use condoms, some men use phrases that compare condoms to “putting on a raincoat while taking a shower”. Because there is so much stigma around wearing condoms, men may refuse to wear them. Survival sex workers may not have the power to make men put on a condom if they are in desperate need of food or money.

The stigma is not just a part of sex work, but also extends to serious relationships and marriages. If a wife suggests that she and her husband use condoms, a husband may think she’s having an affair. At the suggestion, a husband may have the grounds to divorce her.

Women, too, may prefer to avoid using condoms in order to get pregnant. For some women, the community can only consider them adults once they become mothers. They might risk becoming infected in order to have children.

War has also helped to spread the HIV/AIDS virus. During war, many women are raped, which increases their chances of infection. For example, before the Rwandan genocide, over fifty percent of the soldiers were infected with HIV/AIDS. By the end of the war, thousands of women have tested positive for the disease. Without a legal system to prosecute rapists, many men will continue to rape and spread HIV/AIDS.

Because women are often treated as second-class citizens, it forces them into behaviors that put them at higher risk for HIV/AIDS. There are many community-based groups (often called NGOs, or non-governmental organizations) that are now promoting women’s rights as a way to stop the spread of HIV/AIDS.

What is the U.S. Doing?
In January 2003, in his State of the Union address, President Bush pledged 15 billion dollars to help fight HIV/AIDS in Africa and the Caribbean over five years, as part of The United States President's Emergency Plan for AIDS Relief (PEPFAR). As of 2015, PEPFAR has supplied ART to more than 9.5 million. More initiatives have sprung up to help the AIDS crises in Africa such as the DREAMS initiative, which launched in 2014 with the goal to provide $210 million to reduced HIV infections in women.

It is necessary to remember that HIV/AIDS is a disease that spreads because of many reasons - not just individual choices. Social environments, political environments, and economic environments affect what people choose to do. Prevention and treatment programs have to recognize the big picture so that they can work to help stop the epidemic.

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