Stopping AIDS in Africa Africa accounts for 70% of all HIV/AIDS cases in the world although it represents only 10% of the global population. More than 25 million Africans live with HIV/AIDS, and 17 million have already died. The response of the international community has been slow and largely ineffective. The UN estimates that Africa will need $3.5 billion just for basic treatment and prevention programs, yet the U.S. donated only $300 million in assistance in 2000. According to the UN Agency for HIV/AIDS (UNAIDS), 25.3 million Africans live with the virus or are dying of AIDS. Barring a miracle or a major change in international attention to the scourge, these Africans will die within the next decade. Despite the horrors of the pandemic, the international response has been limited and only recently have most African governments begun to publicly address the problem. African governments are hobbled by poverty, cultural taboos about sex, and misperceptions about the cause and seriousness of AIDS. They also fear disruption of precious tourism and investment dollars from the West and have failed to warn their citizens about the dangers of AIDS. Western nations, including the U.S., have largely ignored the dangers and international repercussions of widespread infection in Africa. The United States in 2000 spent only $300 million for basic AIDS care and prevention programs in Africa- far short of the $3 billion regarded as necessary to slow down the pandemic. The HIV/AIDS crisis in Africa is of the gravest magnitude. Every day, 6,700 families lose a loved one to the disease; the construction and sale of coffins is one of the fastest growing occupations in southern Africa. Sixteen African countries have one-tenth or more of their population infected with HIV, and Africa is home to 95% of all mother-to-child transmissions of HIV. In these countries, almost 80% of all deaths of young adults aged 25- 45 will be directly linked to AIDS . A remarkable development in the evolution of the AIDS epidemic has been the ongoing movement of AIDS activists to speed the testing and release of experimental drugs by the FDA, to participate in the design and “implementation of clinical drug trials, and to have a voice in shaping the AIDS/HIV research agenda” (Nixon 1991). The struggle over AIDS drug trials and treatments has required sophisticated technical information about the structure and functions of the FDA, the Department of Health and Human Services, and the NIH. AIDS/HIV treatment initiated with the development of protease inhibitors and sophisticated combinatory treatment regimens; and the structural inequalities, both material and conceptual, that the epidemic has so relentlessly exposed.

AIDS treatment activism and the still more ambitious activist engagement with clinical and basic research offer an extraordinary demonstration of how to have theory in a crisis. Recently, the prevalence of contraceptive use has increased in Africa. The twin risks of unwanted pregnancy and HIV/AIDS infection remain central concerns of reproductive health programs. However, one does not know how sexually active men and women perceive these risks, nor the strategies they consider appropriate to cope with these risks, nor the difficulties they face in trying to adopt appropriate sexual behaviors to minimize them. The recent increases in contraceptive use in eastern and southern Africa are taking place in the context of a high prevalence of sexually transmitted diseases (STDs), including human immunodeficiency virus (HIV). A multi-country study was conducted to describe individuals’ perceptions of risk with regard to unwanted pregnancy and STD/HIV infection and related factors. The countries participating in this study were Kenya, South Africa, Tanzania, Uganda, Zambia, and Zimbabwe. In each country, the study focused on one district with an urban and rural population. The overall aim of the study was to inform policymakers and program managers by providing insights into the perspectives and behavior of “sexually active men and women with respect to family planning, STD/HIV, and reproductive intentions” (Ellerbrok 1999). The study had three specific objectives: to ascertain sexually active individuals' perspectives concerning the risks of acquiring HIV/AIDS and of experiencing an unwanted pregnancy; to investigate the strategies considered by these individuals to be appropriate, practical, and effective in coping with these risks; and to explore the opportunities for and constraints to changing behavior, with particular emphasis on communication between partners. Little, if any, communication between partners was reported concerning family planning and STD prevention, particularly within marriage. Cultural and religious beliefs, lack of knowledge, and men’s obstinacy all contributed to this lack of communication. The KDHS recorded 34 percent and 27 percent in 1993 and 1998, respectively, of currently married female and male respondents who knew of a contraceptive method but had never discussed family planning with their partners in the year preceding the survey. A corresponding figure of 31 percent was recorded in 1993 for males. The first step in a rational process of making decisions about reproductive matters involves spousal communication.

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Clearly, programs of information, education, and communication must be devised to address existing socio-cultural hindrances to spousal communication and decision making so as to counteract their effect on contraceptive use. African men are socialized to exercise complete authority in decision making concerning all important family matters including reproductive health. Yet population and health programs have made little provision for male involvement. As a result, men have not benefited as much as women have from the provision of information regarding the advantages of modern contraceptives, and where to obtain them. Men have, therefore, become vulnerable to rumors and misinformation that have made them not supportive of family planning practices. While encouraging family planning clients to use dual methods (a long-acting method for contraception and a barrier method for preventing transmission of STDs), programs should use “clear and persuasive messages, accompanied by male-motivation initiatives and couple counseling in order to reduce resistance to condom use” (Williamson 1991). Prevention, early diagnosis, and treatment of STDs have been shown to have significant positive impacts on HIV transmission. Clearly, people must be educated to avoid multiple partners, to use condoms correctly and consistently, and to seek treatment for STDs. Condom use must be promoted, dual-method use encouraged, and spousal communication fostered. Innovative programs must be developed to promote responsible sexuality in order to prevent unwanted pregnancies. Information on reproductive health issues and access to family planning services must be offered, especially to adolescents. In order to address the problem of unwanted pregnancy, the government must review and revise its declaration that contraceptives should not be made available to unmarried youth and other forms of family-life education programs must not be imparted in African schools. In the past, family planning programs focused on women to the near exclusion of men. Because men have more sexual partners than do women, because men tend to control the frequency and form of intercourse, because women are physiologically more susceptible to HIV infection, and because most women are economically dependent on men, men's behavior eventually determines how quickly and to whom HIV is transmitted. Therefore, helping men to protect themselves from acquiring HIV is an important step in protecting women, both in stable relationships and during casual contacts. In light of the central role men play in reproductive health issues and decision making, programs should enhance male involvement.

This effort can be expected to promote spousal communication and increase the level of condom use. Despite their awareness of the potential dangers, most focus-group participants reported that they continue to engage in high-risk sexual behaviors. Clearly, information alone is not sufficient to motivate change. In the absence of a vaccine or a cure, the main challenge to AIDS prevention is to move people from awareness to behavioral change (for example, sexual abstinence, partner limitation, and condom use). Promotion of a community’s involvement in the process of behavioral change requires person-to-person communication, increasing individuals’ perception that they are susceptible, that positive consequences outweigh negative ones, and that they possess the skills to make such changes. During the dissemination of the preliminary results of the study to the focus-group participants in November 1998, the action of presenting the findings was observed to carry some motivating factor for behavioral change. In the seminars, participants proposed coping mechanisms for themselves, including sexual abstinence, increased condom use, and being faithful to one’s partner while improving the quality of sexual activity. In six countries of southern Africa, by the year 2005, AIDS will claim the lives of between 8 and 25% of today's active physicians. Women are affected more by this dreaded disease; in Africa, 12 women have HIV/AIDS for every 10 men. African women account for 85% of all global female infections. In southern Africa, one in four women aged 15-49 live with HIV/AIDS. In some countries, between 10 and 20% of teen-age girls are already infected. Infected girls are more likely than boys to drop out of school, reversing decades of slow but steady progress in female education. The much-vaunted African extended family system is faltering, as the number of orphans living without the care of extended families rises. By the year 2010, the projected number of orphans may exceed 40 million in Africa. Africa’s hard-won health and education gains in the 1960s and 1970s were undermined by debt and by externally dictated structural adjustment policies in the 1980s and 1990s. Today, however, social services and economies are imploding from the deadly consequences of AIDS. In the coming decades, the continent will record significantly sharper declines in life expectancy rates and shrinkage of national economies from the effects of the epidemic. Africans living with HIV/AIDS have limited or no access to lifesaving anti-retroviral medicines that have changed the course and management of AIDS in Western countries.

Less than one-tenth of one percent of Africans living with AIDS have access to AIDS drugs. The World Bank estimates that half of all Africans live on $0.65 cents per day. The economic resources of African governments are equally meager, and they are burdened by $20 billion in annual foreign debt payments. With the rudimentary “healthcare infrastructure of African countries, the strain of long-term hospitalization of AIDS patients is taking a heavy toll” (Abramson 1993). Economic underdevelopment and Africa’s impoverished conditions have created a wide-open gateway for HIV infection, tuberculosis (TB), and sexually transmitted diseases (STDs). According to the World Health Organization, an estimated 30-50% of all TB patients in Africa are also infected with HIV/AIDS. Africa has the highest rates of STDs in the world. STDs facilitate the spread of HIV infection, especially among women. Political instability and violent conflicts keep many African governments from focusing on the AIDS crisis. Twenty of the continent's 53 countries are involved in intrastate or interstate conflicts, which lead to having the world's largest regional concentration of refugees.

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