Unlike many African countries, where government AIDS programs have been desultory, the Botswanan government is at war against the virus. Anti-AIDS banners are everywhere, and news about the epidemic appears daily in newspapers and on the radio and TV. Free condoms are available in remote clinics, bars, and shops. Botswana’s was the first African government to offer free treatment with antiretroviral drugs. The government has also funded a Danish-run program that employs field-workers to bring the message of HIV prevention to every household.
Despite these efforts, the HIV epidemic in Botswana shows few signs of abating. Harvard anthropologist Edward Green, who also serves on the Bush administration’s Presidential Advisory Council for HIV and AIDS and is the author of Rethinking AIDS Prevention, believes he knows why. Like many government AIDS programs in Africa, Botswana’s has been heavily influenced by Western donors, who have spent billions of dollars promoting condoms but have placed little emphasis on advising people to have fewer sexual partners. Studies show that even when used consistently, condoms fail to prevent infection 10 percent of the time, due to breakage and human error. In any case, most people do not use condoms every time they have sex but only with prostitutes and casual partners. Many people use them early in a long-term relationship but then dispense with them later on as a gesture of trust. But these long-term relationships are the very ones that Morris believes are the most risky.
The solution, says Green, is for people to limit themselves to one sexual partner. In Uganda, where the slogan of the government HIV prevention program in the 1980s and 1990s was “zero grazing,” HIV rates have fallen from 18 percent in 1993 to around 6 percent today. A report from the United States Agency for International Development says the number of men with casual sexual partners fell from 35 percent in 1989 to 15 percent.
Other governments, including Botswana’s, have begun campaigns like Uganda’s, with mixed results. Why haven’t these campaigns been more successful? In many places where HIV rates have fallen, widespread behavioral change has been accompanied by extraordinary activism. In the early 1990s, there was a vibrant movement devoted to the fight against AIDS. Hundreds of community-based organizations and activist groups had sprung up, most run by women. Uganda has Africa’s oldest, most vigorous women’s movement, dating back to the 1940s. In the 1980s, activist women made AIDS part of their struggle, which added enormous momentum to the government’s zero-grazing campaign. In many respects, the fight against AIDS in Uganda resembles the fight against AIDS in the United States in the 1980s, when gay men came to see the struggle against HIV as part of the struggle for gay rights. As the movement gained strength, the HIV rate among these men rapidly declined, just as in Uganda.
Botswana’s women’s movement is only 20 years old. The government is listening to women as never before, but much remains to be done to improve the everyday lives of women at risk for HIV. Traditions of protest are weak in Botswana. Fighting AIDS may depend on an anger that the women of this long-contented nation are only beginning to acquire.
MALE CIRCUMCISION AND HIV For years researchers have puzzled over why most West African countries have lower HIV-infection rates than southern and East African countries. They thought it might have something to do with the Muslim religion, widely practiced in West Africa, which imposes restrictions on women’s sexual freedom. However, another likely factor is male circumcision, which is ritually practiced by Muslims and many others. Several studies suggest that male circumcision protects both men and their sexual partners from HIV infection. This is not true of female circumcision, or female genital mutilation, which is extremely dangerous. In African countries where male circumcision is common, such as Senegal, Mali, Ghana, Benin, and the entire region of North Africa, HIV rates tend to be much lower than in countries such as Botswana, Malawi, and Swaziland. In countries with high rates of HIV, provinces and districts that have high rates of circumcision, such as Inhambane in Mozambique or Dar es Salaam in Tanzania, tend to have lower HIV rates. Two African tribes with very high HIV-infection rates are the Zulu of South Africa and the Tswana of Botswana. Before colonial times, men in both tribes underwent circumcision rituals during adolescence. But when King Shaka united the Zulu tribe in the 1820s, he abolished the ritual, and when Christian missionaries settled in with the Tswana in the late 19th century, they declared circumcision a barbaric practice. Circumcision removes mucosal tissue and cell types in the foreskin that contain special “receptors” for HIV. Some estimates suggest that circumcision may cut a man’s risk of contracting HIV by 70 percent. If true, this would mean that male circumcision may prove more effective than any of the HIV vaccines undergoing clinical trials. It would also be much cheaper, carry few side effects, and require no booster shots. Randomized, controlled trials of circumcision for HIV prevention are under way in South Africa, Kenya, and Uganda, and the results should be known within three years. —H. E. |
