JCTR Bulletin 49 - Artilce on AIDS

In Zambia approximately one in every 10 persons has HIV or AIDS. In Ghana it is one in every 60. In Great Britain it is one in every 1,900. Why are there such great differences? In particular, why are Zambia and other countries in Eastern and Southern Africa so badly affected?

There is also another puzzling feature. In Zambia and elsewhere in Africa the survival time from initial HIV infection to death usually ranges from five to seven years. In the United States, however, people with HIV can live in good health for more than a decade, while some live for as long as 15 years without becoming ill with AIDS-related sicknesses.[2] Again, one asks why it should be so.

There are three possible reasons for these differences. First it could have something to do with the virus itself. Second, it could have something to do with the way HIV is transmitted, that is, with behaviour patterns. Finally, it could be because of conditions inherent to individuals who contract HIV. Let us look at each of these possibilities.

Differences in the Virus do not Explain Differences in HIV Prevalence

There are different types and sub-types of HIV. The sub-type that is ravaging Zambia and this part of the world is different from the sub-type that predominates in West Africa, and both are different from the sub-type that is encountered in the United States. One could ask whether the HIV virus that infects people here (HIV-1) can be transmitted more easily than the type of HIV-1 that is at work in other parts of the world. The answer is that there is no evidence that the various sub-types of HIV-1 differ from each other in the ease with which they can be passed from one person to another. The HIV sub-types that occur in Eastern and Southern Africa are not themselves the reason for the very high levels of HIV/AIDS that are experienced here compared with other parts of the world.

Differences in Patterns of Sexual Activity do not Explain Differences in HIV Prevalence

A second possibility is that behaviour patterns in Zambia and neighbouring countries differ from those in other parts. Since hetero-sexual behaviour is what causes most of the HIV transmission here, this possibility, if true, would imply that the pattern of sexual behaviour here differs from what is found elsewhere. A different pattern in sexual behaviour could mean either that in Zambia and neighbouring countries there is more of the risky sexual activity that leaves one open to possible HIV infection, or simply that more sexual activity occurs here than in other parts of the world. If either of these were true, then a higher level of promiscuity would go a long way towards explaining the high levels of HIV/AIDS that we are experiencing.

But sexual behaviour alone cannot explain the differences in the way HIV has spread in Eastern and Southern Africa compared with the rest of the world. There is no evidence that promiscuity in Zambia or in the neighbouring countries is higher than elsewhere. In fact, all the evidence indicates that when it comes to promiscuity countries tend to be very similar. Careful studies have shown that risky sexual behaviour patterns, such as high rates of partner change, frequency of contacts with sex workers, or keeping several sexual partners “going” at the same time, are just as likely in West Africa, where HIV prevalence is low, as in Ndola, where it is high. In the United Kingdom, 27% of men report having sex with a non-regular partner, the very same as in Zambia. But the HIV prevalence rate in Zambia is more than 200 times higher than in the UK. Something other than the pattern of sexual behaviour must be leading to such a difference.

That differences in sexual behaviour do not fully explain why HIV infection has spread so rapidly in Zambia is also borne out by evidence about rates of mother-to-child transmission. In Africa, 25–40 percent of infants born to HIV-positive mothers are likely to be HIV infected; in Europe this is the case with only 14 percent of infants and in the United States with 17–25 percent. In this case there is a complete absence of any form of sexual behaviour. Yet a new-born infant of an HIV-positive mother in Zambia is two to three more vulnerable to HIV infection than an infant in similar circumstances in the developed world.

Clearly this has nothing to do with promiscuity. Instead, it is telling us that for some reason an infant born in Zambia, or Africa, is intrinsically at considerable risk of contracting HIV. The Zambian infant is more likely than the US or European infant to contract HIV infection. But this is so not only for infants. Almost everybody living in Africa is somehow more susceptible to HIV infection than those living in other parts of the world. This is not because of the type of virus. It is not because of excessive or uniquely high-risk sexual behaviour. It is because of the third reason: there is something in the condition of those living in Zambia, and elsewhere in Africa, that makes them very vulnerable to HIV/AIDS infection.

Differences in Nutrition, Health, and Hygiene Conditions can Explain Differences in the amount of HIV/AIDS

Specifically, the nutrition, health, and hygiene conditions of those living in Africa make them particularly susceptible to HIV infection, in the same way that they are particularly susceptible to infection from other viruses and bacteria (such as those that cause cholera, a disease that has tended to flourish across the same period that HIV infections grew).

There are four health-related conditions in Zambia that go a long way to explaining why this is so. They are under-nutrition (or malnutrition), deficiencies in micronutrients, carrying a heavy load of parasites and worms, and untreated sexually transmitted infections (STIs). Unsafe water and sanitary conditions also play a role.

The extent of malnutrition was highlighted earlier this year in the JCTR’s analysis of Zambia’s socio-economic status: “Recent data show that about 60% of the children are malnourished, up from 47% in the early 1990s. More than half the Zambian children are stunted and almost 25% underweight (JCTR, February 2001 Update). This quotation makes two things clear. First, back in the early 1990s malnutrition rates among children were already extremely high, and second, the position has since grown considerably worse. Many of the children who experienced malnutrition in the late 80s and early 90s are today’s adults. Now aged 15 and above, they are among the ones most severely affected by HIV. A very large proportion of these have experienced chronic malnutrition throughout their lives. They seldom had enough calories and proteins to sustain active growth and a life of work. For many this situation continues.

Malnutrition weakens a person’s immune system. First, it weakens the body’s initial lines of defence, the skin and the mucus membranes. The healthy skin of an adequately nourished person effectively blocks the admission of a virus while the mucus engulfs and carries away any that may be admitted. In a malnourished person, these systems are not able to block infection in the way they should. The frequency with which a malnourished person develops sores on the lips or infections in the eyes shows us this quite clearly. Second, malnutrition reduces the ability of blood cells and bone marrow to produce the immune response that is needed to cope with an infection—any infection. Of particular relevance to HIV is the fact that protein deficiency leads to a reduction in the size and weight of the thymus, the gland that produces the all-important protective T-cells.

This being the case, it comes as no surprise to learn that when nutrition levels decrease, HIV prevalence levels increase. Across countries, increases in HIV prevalence are strongly associated with falling consumption of proteins and calories: the more severe the deterioration in nutrition, the higher the HIV prevalence rate.

Micronutrients are essential nutrients which the human body cannot manufacture but which it needs in only small amounts for the efficient functioning of the brain and the proper operation of the immune system. Deficiencies of even the small amounts that are required increase a person’s vulnerability to infection. In Zambia, iron deficiency (which leads to anaemia) is so common that it is believed to affect almost all school children and up to half of the adults. Iron is essential in promoting resistance to infection. Zinc deficiency, which is also widespread, also reduces resistance to infection and impairs the self-healing power of the skin and tissues.

But the most serious condition—and one- that is very widely experienced—is vitamin A deficiency. Inadequacy of vitamin A impairs the body’s immune system in three ways—by weakening the skin and mucus membranes, by reducing the ability of bone marrow to produce protective cells, and by reducing the ability of blood-cells to provide the necessary protection. Children who lack vitamin A may be in danger of blindness, because their systems cannot protect the mucus membranes that surround the eyes. The night-blindness that is endemic in the North-Western, Western and Luapula Provinces is a manifestation of extensive vitamin A deficiency, but the problem occurs in other areas of the country also, especially during the dry season.

Iron and vitamin-A deficiencies occur because of the shortage of these micronutrients in the diet. They also occur because diarrhoea, frequently caused by unsanitary conditions and contaminated water, flushes them out of the system. Both sets of circumstances combine to leave a large proportion of the people in Zambia, and elsewhere in tropical Africa, with chronically impaired immune systems that are dangerously susceptible to infection by any virus or bacterium that might come along, HIV included.

Malaria is the most widespread disease that afflicts Africa. Of the 300–500 million annual cases of malaria worldwide, more than 90% occur in tropical Africa. Although certain drugs take away malaria symptoms, they do not kill all the parasites that may remain in the body’s system (and that can lead to renewed bouts of fever). There are other parasites also. Bilharzia is almost endemic in Zambia, with very high rates occurring in individuals who come into contact with a combination of slow-moving or stagnant water and water-borne vegetation. In addition roundworms, whipworms, hookworms, and amoebae are very widespread, with many individuals carrying several of these at the same time.

This parasite load undermines nutrition and increases the need for micronutrients. The simple reason is that if they are to survive within the body the parasites must draw their sustenance from their human host. Millions of people in Africa are sharing their meagre intake of foodstuffs and micronutrients with billions of parasites. This impact on nutrition and micronutrient supply further weakens the natural defence systems of infected persons, leaving them more vulnerable to infection.

In addition, parasites have another negative effect. They keep the immune system in a perpetual state of alertness in an effort to ward off the infections to which the parasites may give rise. This reduces the immune system’s ability to identify and react to newly introduced parasites, almost as a piece of elastic loses its elasticity if it is kept tightly stretched all the time. The exhausted immune system fails to spot new invaders or is incapable of mounting the response needed to protect the body. The result is greater susceptibility to infection, particularly by a relatively new virus such as HIV.

It has been recognised for a long time that STIs facilitate the transmission of HIV. However the type of STI is also important. The United States reports about 12 million new STI cases annually, yet there are fewer than 900,000 HIV positive cases in the US. The high incidence of STIs does not seem to be accompanied by an equally high incidence of HIV infection. This is related to the fact that the STIs that commonly occur in the United States do not cause ulcers in the genital area. It is different, however, in Africa where a very common STI is chancroid. This causes genital ulcers. Moreover, this and other genital ulcer conditions occur most commonly where the scarcity of water makes it hard to maintain personal hygiene, a situation that is all too familiar in both rural and urban Zambia. Susceptibility to genital ulcers is also increased by malnutrition and vitamin A deficiency, especially when there is a combination of these, because of the way these two conditions weaken the skin and mucus membranes. When there are genital ulcers, the risk of HIV transmission becomes five to ten times greater than otherwise.

What makes this situation worse is that many people do not know that they have an STI, many who do know do not look for treatment (because of shame or because of costs associated with going to a clinic or doctor), and many who look for treatment cannot get it (because clinics or health centres do not have the necessary medications).

It is clear from the above that there are two major explanations for the amount of HIV and AIDS in Zambia. Sexual behaviour is one explanation. The second is the nutrition, health, and hygiene status of those who engage in sexual behaviour. Both must be taken into account. Neither one alone tells the whole story. Addressing one without addressing the other is a recipe for failure. A policy that focuses narrowly on behaviour change, but does not simultaneously focus on improving the general nutrition, health, and hygiene conditions of people, will not succeed in stemming the HIV epidemic.

This underlines the importance of taking the broad view of HIV/AIDS, especially by seeing it in the context of poverty. President Mbeki of South Africa has drawn much criticism for the way he has linked HIV/AIDS to poverty, but his views in this regard received international endorsement at the end of June when a special session of the United Nations General Assembly unanimously agreed that “poverty, underdevelopment and illiteracy are among the principal contributing factors to the spread of HIV/AIDS” (Declaration of Commitment, §11).

The need now is for ever more determined and holistic efforts at poverty reduction, seeing these as also targeting HIV reduction. Anti-AIDS programmes should not be stand-alone activities that focus almost exclusively on sexual behaviour. Instead, they should be firmly rooted where they belong, within a poverty-eradication framework that gives prominence to programmes that

· safeguard the ability of every person to meet essential nutritional requirements,

· ensure that clinics and health centres are adequately stocked with essential drugs and that the infrastructure is in place to make these freely available to those in need,

Anybody who promotes programmes like these is promoting the struggle against HIV/AIDS.

An article in the July-August 2001 edition of New People indicts the Structural Adjustment Programmes (SAP) imposed by the IMF and World Bank as an indirect cause of the socio-economic vulnerability of children to AIDS. The argument should be widened. The IMF’s own evaluation of the SAP in Zambia shows the way SAP measures were accompanied by an increase in malnutrition, a decrease in the value of health services, and an extension in cost recovery for the limited health services that were available (at a time when drought and badly sequenced SAP measures made it impossible for large numbers to pay any costs). In the light of what was said earlier in this article, this worsening of the health situation in the first half of the 1990s has made a major contribution to the high levels of HIV/AIDS experienced today.

Since HIV/AIDS first came on the scene in 1981 sufficient attention has not been paid to ensuring health care, medical supplies, water and sanitary infrastructure, and food security. This neglect has left the people of Zambia very susceptible to infections of all sorts, HIV included. A weakened people were easy targets for an insidious, complex, patient, and virtually indestructible virus such as HIV. Much of the blame lies within Zambia—with bad governance, poor policies, mismanagement of financial resources, corruption and the diversion of funds. Much also lies outside Zambia—with the economic measures imposed by the international financial institutions. Is there any possibility that the perpetrators of what is now a national catastrophe will be brought to book? Or will the people of Zambia have to impoverish themselves even more by borrowing in order to deal with a situation for which both leaders and lenders must bear considerable responsibility?

Article prepared for JCTR BULLETIN
[NOT TO BE REPRINTED WITHOUT PERMISSION]

[1] Much of this article is drawn from a paper by Professor Eileen Stillwaggon, University of Gettysburg, USA. Professor Stillwaggon, an economist, first presented her material to the Durban International AIDS Conference in July 2000 and subsequently published it in the South Africa Journal of Economics.

[2] This is how it was before the anti-retroviral drugs came into use. Access to these drugs in rich countries has extended the life prospects of persons with HIV to an extent that is very considerable, though not yet accurately known.