HIV: Looking in the Ugly Mirror

HIV: If there is a more grimly fascinating epidemic, I would like to read about it. Close as I am to finishing my year living amongst this dark plague, I must admit that I still find more to puzzle over than to understand and more questions to ask than I can claim to have answers for, particularly when it comes to the vexed topic of preventing new infections. I retain a mental image from my first days here, that somehow HIV manages to be humanity’s ‘ugly mirror’ reflecting and even emphasising many of our worst behaviours and traits, asking questions that we struggle to respond to let alone resolve.

There are literally a hundred ways to look at the epidemic and just as many hypotheses as to why the virus has been so uniquely successful in Southern Africa. They range from the sociological (long term concurrent sexual partnerships remain common in African societies), to the geographical (a continent of truck routes and migrant workers are uniquely useful for the virus’s transmission), from the political (HIV was brought to the continent by white men to suppress nascent African nations), to the downright paranoid (HIV was developed by my colleagues – those dark figures in white coats from the pharmaceutical industry – to enable us to make lots of money selling ARV’s) to name just a few.

It says something about the breadth and scale of the pandemic that arguments in polar opposite directions can be put forward and yet I can still find myself nodding in agreement with both: HIV is a disease of poverty – look how it hits the poorest countries with the weakest infrastructures hardest; HIV is a disease of affluence – look how the richest in society have the highest rates of infection due to their money to attract many sexual partners. And on and on it goes, Hans Rosling does a remarkable job of demonstrating the diverse evolution of the epidemic with stunning visuals here.

Living in the shadows of sex and sexuality, with its delayed onset of symptoms – so nobody is ever really sure who is sick and who is well, or for that matter who infected who, HIV does a remarkable job of being everyone’s bogey man. The religious can use it to call for deliverance from the sins of sexual promiscuity, the socially conservative can use it to attack those outside the cultural mainstream (men who have sex with men, commercial sex workers, injecting drug users etc.), and in the case of South Africa’s recent period of AIDS denialism under Thabo Mbeki  – a whole government can use it as evidence of a gross conspiracy against it by the world at large (a policy recently and forcefully renounced by Jacob Zuma I am happy to report).

The biggest problem is that this kaleidoscope of perspectives permits for an even more diverse range of prevention messages to emerge, each with a degree of validity to them, but collectively quite easily bewildering or even contradictory. Abstain from sex / if you must have sex use a condom (unless your church prohibits it )/ if you must have sex but can’t use a condom then get circumcised / if you are circumcised then remember that the protection is only partial and for the man not the woman / the best way to protect a woman is to economically empower her so lets forget about talking about sex altogether and focus on that instead. Can we really be surprised that this melange of messages, even when backed by large amounts of money, have failed to inspire clear and consistent behaviour change amongst the masses?

Meanwhile, the rate of new infections remains stubbornly high across the region and is rising sharply in other parts of the continent. The human scale of the tragedy continues to grow to Stalinistic proportions with numbers so large the mind fails to comprehend. Lets keep it simple, in little Zambia with its 12 million inhabitants, on this very day over 230 people will become newly infected, about 200 others will die and there will be many more additions to the 1 million orphans already left behind.

Zambia is fortunate that there are still many donors willing to finance and support its efforts to change the course of its epidemic. Yet I am sorry to say that all these well meaning donations are doomed to continued failure if they fail to encourage Zambians themselves to identify and embrace the changes of behaviour that are required to save themselves. When I think of all the well meaning non African minds who are typically responsible for designing and even implementing such donor driven behaviour change programs, I can’t help but be struck by the vast differences in attitudes and behaviours between our cultures that we all too often choose to ignore or worse try to override.

Imagine for a moment, if the boot were on the other foot, and it was Africa who had the economic power and with it the aid largesse. Were their aid agencies to visit our Western societies I am quite sure they would be horrified to see the state in which we keep many of our older generation – locked away in semi-squalid, semi-prisons awaiting their ignominious departure from this earth. Imagine if they were then to suggest a huge behaviour change programme to ‘sensitize’ us to the value of our elders and mobilise us to take better care of them. I am not sure how well their well meaning aid and advice would be accepted.

And so we reach an inconvenient truth, that HIV merely reflects the patterns of behaviour of any given society and it is only from within that society that the necessary changes can be made to alter its course. When the disease was rampant in the gay communities of New York and San Francisco in the early 1980’s it was an unpopular decision to forcibly close the bath houses where so much of the unprotected sex was occurring – unpopular but ultimately the right one.

Zambia is now faced with far more difficult choices. Does it push hard to change long-standing behaviours regarding multiple partnerships? Does it move away from the ‘voluntary’ component of testing  towards more directive ‘diagnostic’ approaches? Does it challenge the second class status of women that is such a powerful driver of the epidemic? There are many options but the choices that will work can only come from the nation itself.

So here is the conclusion I take, no amount of donor money or technical support is going to provide what ultimately must come from the people themselves. They know the issues, they have seen more of their friends and family die than we could ever imagine and it is up to them to decide how to stem this bloody tide. Only when Zambia comes forward with its own solutions reflecting its own cultures and values and the collective will of its own people will they be able to look straight into the HIV mirror and see themselves clearly (and beautifully) once again.

One Response to “HIV: Looking in the Ugly Mirror”
  1. Ali Watkins says:

    Another great article BV.

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