AIDS and Poverty in Africa

The decision by pharmaceutical companies to withdraw their patent suit in South Africa removed an important obstacle to access to antiretroviral treatment of HIV/AIDS in the developing world. Drug copiers, such as Cipla Ltd. of India, have offered to provide a three-drug combination for about $350 instead of the $10,000 to $15,000 paid in the United States for one year's treatment at patent-protected prices. Even at Cipla's price, however, treatment of HIV/AIDS raises serious questions of feasibility for very poor countries.

But treatment of people with HIV/AIDS is not only the compassionate solution, it is also cost-effective. The cost of not treating AIDS includes the burden of opportunistic infections in, and early death of, 25-35 percent of the work force in the next decade. The additional impact on the economy and society of a generation of 6-year-olds raised by 11-year-olds cannot be adequately addressed in macroeconomic models of the cost of HIV/AIDS. Access to treatment is a necessity for Africa.

What might be overlooked, however, as life-sustaining drugs become available, is the fact that prevention is still by far the more compassionate and more cost-effective answer. Prevention does not replace treatment, but it does reduce the number of people whose lives will depend on expensive drugs with significant side effects. The key to a good prevention program is understanding the dynamics of disease transmission. But most prevention programs have been extremely narrow in scope. International AIDS policy derives from an erroneous preconception that the high rate of HIV transmission in Africa is primarily an issue of sexual behavior that can be addressed by behavior modification. That policy has met with some success in the United States and other rich countries. In Africa and in similarly impoverished populations, however, biological factors that result from poverty play a determining role in the high rates of HIV transmission. Failure to recognize those biological factors and to integrate them into a model of transmission for poor populations has led to prevention strategies that have failed and to the perpetuation of racial stereotypes.

Sexual behavior is obviously an important factor in the transmission of sexually transmitted diseases. Education programs have been very successful in Uganda in reducing incidence (new cases) in recent years. But sexual behavior alone cannot explain HIV prevalence as high as 25 percent of the adult population in some African countries and less than 1 percent in the United States. The presumption that high rates of partner change explain the very high rates of HIV is generally not explicit. But it is the implicit assumption behind an AIDS-prevention policy that consists of behavior modification and condom provision, with some recent attention to sexually transmitted diseases (STDs). There has been very little analysis of the myriad factors that influence HIV transmission in a profoundly poor region.

The question is straightforward: How is AIDS different in Africa? Instead of being addressed with mainstream methods of scientific inquiry, the AIDS-in-Africa debate was hijacked in the 1980s by an extreme behavioralist explanation that transformed the question into: How are Africans different? So ingrained in Western thought is the notion of racial difference that the distortion of the question went unnoticed, and the behavioral approach has dominated both research and policy for more than a decade.

The justification for a behavioral explanation of African AIDS was found not in careful empirical studies but in hypothetical arguments based on a powerful racial metaphor that portrays Africans as a special case. The literature that formed the basis of AIDS policy is characterized by sweeping generalizations about an imagined pan-African culture of sex as a commodity and fertility as a duty to one's ancestors. Unlike most scientific and social science work, the literature on African sexuality relies on suggestive language, double-entendre and innuendo. It also resembles a pyramid scheme, since almost all works cite the same few anthropological studies of the 1980s that designate Africa as the "domain of Homo Ancestralis," a hypothetical early stage of human development in which sexual relations were unencumbered by Eurasian patriarchy. The social science literature on "African sexuality" exhibits much lower standards of proof than would be required for publications on European or North American subjects. The momentum of Western stereotypes clothed in social science jargon compensates for the empirical weaknesses of the works. The use of species terminology in the designation of Africans as Homo Ancestralis is a metaphor that inescapably carries the intellectual baggage of nineteenth-century racial science, which maintained that Africans were a genetically distinct species from Europeans. The ease with which the image of hypersexualized Africans was incorporated into AIDS policy indicates the persistent force of this nineteenth-century racial view. The emphasis on racial difference is evident in the terminology used to describe multipartnered sex in Africa and in the West. Africans are described as being polygamous, which lends an exotic air and marks Africans as the social "other," whereas Westerners simply have multiple partners.

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