The Unwritten Sociology of HIV

Alex de Waal

  • Aids in the 21st Century: Disease and Globalisation by Tony Barnett and Alan Whiteside
    Palgrave, 416 pp, £52.50, June 2002, ISBN 1 4039 0005 1

The first anecdotal evidence that Aids-related illness and death were contributing to a crisis in African farming came in the mid-1980s; the first consultants’ reports and academic studies were completed by about 1990. But even the international agencies that sponsored these studies, including the Food and Agriculture Organisation and the Department for International Development, somehow ignored the findings when designing their assistance programmes. It is only now that rural development and food security programmes in Africa are beginning to take account of the implications of Aids.

A report published by the International Crisis Group (ICG) in 2001 compared the impact of HIV on Africa to that of a war. The prologue was written as a war reporter’s dispatch from Botswana. Eighty per cent of the country’s hospital beds were filled with casualties, 20 per cent of the national budget was devoted to war expenditure, the economy had contracted by 30 per cent, and young people had begun dying in such numbers that life expectancy had dropped to ‘medieval’ levels. But Botswana is not only not at war: it is Africa’s most prosperous nation. The figures refer to the probable impact of Aids a few years from now.

In sub-Saharan Africa, the war against Aids must be fought on terrain long since overrun by the enemy. Across the continent, 29.4 million people are estimated to be living with HIV or Aids, about 70 per cent of the global total. Of the five million new HIV infections and three million Aids deaths in 2001, the majority were in Africa. Fifteen years ago, life expectancy at birth in Southern Africa was in the sixties and creeping higher: it was commonly assumed that, over time, Africa would close the gap on Europe. Today, in Southern African countries life expectancy is plunging to the mid-forties and below, while in Europe and America it is predicted that within a few decades we may live to a hundred years or more.

HIV/Aids spreads unusually slowly for an unchecked epidemic. The graph of an epidemic in the acute stage is like a slanted ‘S’. From a single case, the number of people with the disease accelerates until it reaches a peak, whereupon a reverse slope follows, usually slower, with the epidemic declining or dying out altogether. Some epidemics, such as cholera or Sars, spread and peak rapidly, in weeks or at most months. With a short incubation period and a high fatality rate, they tend to burn themselves out before they spread too far. The most feared untreatable diseases, such as Ebola, which causes haemorrhagic fever and death within a few days, flare up in spectacular fashion and abate very quickly.

An HIV/Aids epidemic is very different. In the absence of effective treatment, it takes an average of eight to ten years for HIV infection to develop into full-blown Aids, leading to death. This gives the virus plenty of time to spread before the epidemic is recognised. Aids can also be mistaken for other diseases, and people who would like to avoid the shame of an incurable sexually-transmitted infection are all too willing not to believe they are HIV-positive. The stealth of the illness and the stigma it entails mean that, two decades into the global Aids pandemic, we are still climbing the slope of the ‘S’: the worst is still ahead.

A great deal is now known about the human immunodeficiency virus, with its multiple strains, frequent mutation and propensity to recombine in new and potentially more virulent forms. But this expertise has had little impact on the lives of the great majority of the 40 million people living with HIV and Aids in the poor countries of the world. Nor has it altered the course of the pandemic. In America and Europe, anti-retroviral therapy has commuted the death sentences of HIV sufferers, who now live with a chronic condition. In Africa, only 0.2 per cent of those living with HIV are currently on a clinically supervised course of ARV. This number is rising fast: the most hopeful sign for a long time. But despite their impact on the life expectancy of people with HIV and Aids, ARVs are merely a holding measure. HIV is still a few steps ahead of the international pharmaceutical industry. Drug resistant strains are a growing fear. Optimists maintain that a vaccine is perhaps a decade or so away; pessimists worry that no vaccine will ever be effective.

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