|
By Mervat M. Mohamed
 |
|
Access to antiretroviral (ARV) treatment in
Botswana. Governments should promote much greater community participation in the provision of HIV/AIDS services.
Courtesy: WHO/Eric Miller |
Background
The overwhelming majority of people with HIV, some 95% of the global total, live in the developing world. The proportion is set to grow even further as infection rates continue to rise in countries where poverty, poor health care systems and limited resources for prevention and care fuel the spread of the virus.
After enduring hundreds of years of oppression, conflict and crisis, Africans now face the most challenging threat to their survival - the HIV/AIDS pandemic. In Africa, 25.3 million people are currently infected with HIV. Specific cultural ideals, identities, and gender roles are crucial factors in the development of particular behaviours that support the perpetuation of HIV. Furthermore, the lasting effects of European colonialism have significantly influenced individual and socio-cultural identity.
Wrong Notion
The notion that the North Africa region has sidestepped the global epidemic - perhaps due to strict rules governing sexual behaviour - is not supported by the latest estimates, which indicate that 75,000 people became infected with HIV in the past year. This brings the total number of people living with HIV/AIDS in the Middle East and North Africa to an estimated 600, 000. AIDS killed a further 24,000 people in 2003. [1]
Hard statistics are difficult to come by in this area of the world. A Ugandan UNAIDS official says, "Most people with HIV do not know they are infected because testing for HIV is not widely available in Africa" [2a, 2b]. There is a deep shame associated with AIDS and most people in this region who die of AIDS do so in silence. Men in particular are rarely tested or know their HIV status. Those women who bravely tell of their sickness are often shunned, ridiculed, and beaten. Because of this stigma, many do not admit that they are dying of AIDS, others do not want to know - and so the cycle continues.
Cultural Implications
Although genetic, biological, political and economic factors influence the susceptibility, continuation, and spread of HIV infection in Africa to some extent, it is maintained that cultural behaviours and beliefs have provided ideal conditions for the deadly HIV virus to flourish in this region. Cultural issues of gender identities, roles, and expectations, marriage and family, sexual practices, and the ways in which males and females identify and relate to one another within their cultural and social constructs play a broad and significant role in the spread of HIV infection.
Policies
Usually HIV/AIDS policies are developed along two axes: moralism/pragmatism and coercion/ compassion. These reflect the different interests and positions to be found within society. The coercion/compassion axis opposes a behavioural disposition emphasizing compulsion or force to one which puts the emphasis on understanding the social needs and plight of people living with HIV/AIDS or those at risk while acknowledging that every human being is a potential victim of HIV/AIDS. The moralism/pragmatism axis opposes a disposition to judge certain types of sexual conduct as morally wrong to one that emphasizes what is practicable rather than what is ideal. Thus four general policy approaches emanate from these two axes:
The approach that lies between coercion and pragmatism. Here policy advocates external but not necessarily punitive, actions targeting those living with HIV and those defined as belonging to high-risk groups seen as dangerous to society. Policies emanating from this approach emphasize containment combined with pragmatic education and prevention.
The approach that lies between coercion and moralism. Here policy is punitive against those living with HIV and those seen as belonging to high-risk groups. There is a bias towards institutional controls, with the infected and members of high-risk groups seen as "them" out there who typify what is wrong with society. Therefore, quarantines are advocated, and the distribution of condoms is opposed as unethical. Policy emphasizes punishment as an example to others. Born-again groups of persuasion have been a vocal minority promoting this policy approach. Some groups even think that discussing risk factors is premature and that preventative measures are unacceptable [3].
The approach that lies between moralism and compassion. Here policy rejects as inhumane mechanisms such as quarantine but also rejects practical interventions such as provision of condoms, sterile needles and sex education on the grounds that they encourage immorality. Policy therefore emphasizes the need for awareness-raising through preaching what is right and wrong. Mainstream churches and traditionalist circles have argued for this policy alternative.
The approach that lies between compassion and pragmatism. Here HIV is recognized as a danger to society, but the rationality of external controls is questioned. Society is seen as having a responsibility to fight the spread of HIV/ AIDS in the most humane way. What is envisioned is a positive interaction between society on the one hand and people living with HIV/AIDS and those at high risk on the other [5]. Here policy endorses the provision of condoms, sterile needles and sex education and resolutely opposes quarantines and compulsory testing of individuals. Policy recognizes that people are not going to stop having sex and emphasizes measures which are humane and practical. The idea is that HIV is a problem that subjectively and hypothetically exists in everyone.
Most AIDS policies in Africa have shunned moralism on pragmatic grounds. Even if it were true that HIV/ AIDS is a result of "immoral" sexual activities, policy makers generally realise that widespread behavioural change will never be brought about by preaching morality or by threats of punishment. There have been important advocates both of HIV disease containment combined with prevention through education on one hand and of doing whatever works without infringing people's rights on the other hand [4].
Women and HIV/AIDS
The prevalence of HIV among women in Africa is of particular concern in the bid to improve the living conditions and health of women because of their connection to pregnancy, childbirth, nursing, and childcare. Consequently, the degeneration of this connection directly impacts the primary family unit and thereby the social structure of the community. According to the Centres for Disease Control and Prevention, "In June 2000, UNAIDS reported more than one in five women under the age of 25 are infected with HIV in Africa" [5].
Child Marriage
The traditional practice of child marriage is another factor that contributes to the spread of HIV among young girls in Africa. North Africa is one of the regions where they are least common [6]. Facing economic hardship, some parents marry off young daughters in order to ease themselves of what they consider an economic liability and to receive a bride price. UNICEF reports that, "For both boys and girls, early marriage has profound physical, intellectual, psychological and emotional consequences, cutting off educational opportunities and chances for personal growth" [7].
Moreover, young girls are also more susceptible to sexually transmitted diseases, including HIV, because their bodies are not fully developed [7], because there exists a general ignorance about reproductive health due to illiteracy and lack of education, and because they may be married off to older and more sexually active men.
Religion
Comparatively, North Africa maintains one of the lowest HIV rates worldwide. It appears, at least statistically, that in countries where there exists a dominant and central religious influence, the HIV rates remain comparatively lower than in countries exhibiting various and sometimes conflicting religious ideals. The African countries most highly infected with HIV - Namibia, Zambia, Botswana, Zimbabwe and South Africa - all indicate a combined presence of indigenous religions and/or a form of Christianity. In North Africa, correlation between cultural-religious ideals and the rate of HIV infection, suggests that the religious unity and prevalence of Islamic religious law provides a social structure that deters the spread of HIV.
Religion should be an important and continued consideration when evaluating the HIV epidemic in Africa. Religious beliefs provide insight as to how a culture perceives itself, how its people approach conflict and relate to crisis.
Conclusion
AIDS policies in Africa have seesawed between containment of victims and potential victims and their sympathetic treatment. Obviously policies, which do not emphasize containment, are preferable. However for these to work, the conditions that make Africa the most AIDS-affected region in the world, must be addressed. Poverty, inequality and underdevelopment must be seriously tackled if real progress is to be made in the fight against HIV/AIDS. [2,8].
The Way Forward
Firstly: the scale of the epidemic requires organized responses that promote effective ways to combat it. Clear-cut policy is necessary to assist behavioural change.
Secondly: HIV/AIDS is accompanied by stigma. The infected and those perceived to be at high risk are widely discriminated against. Such discrimination violates or undermines the basic human rights of certain groups of people in society. Policy is necessary to safeguard these rights both as a matter of ethics and as part of the strategy to combat HIV.
Thirdly: policy is also necessary to deal with the escalating costs of the disease, especially with regard to education and employment.
Governments should promote much greater community participation in the provision of HIV/AIDS services by decentralizing the management of programmes and by forming partnerships in cooperation with local non-governmental organizations and private health-care providers. All types of non-governmental organisations, including local women's groups, youth and religious groups, should be encouraged to become involved in HIV/AIDS programmes.
References
1. HIV InSite. <http://hivinsite.ucsf.edu/InSite.jsp?page=cr-o2-01>.
2. Altman, Lawrence K. "AIDS Virus Originated Around 1930, Study Says".
The New York Times. Feb. 2, 2000.
2b. Altman, Lawrence K. "U.N. Warning AIDS Imperils Africa's Youth".
The New York Times. June 28, 2000.
3. Osei-Hwedie, B and Osei-Hwedie, K., 1996, The Social Context of HIV/Aids Policy in Southern Africa: Some Emerging Issues Paper Presented at the Nineteenth SAUSSC Conference, Mmabatho, South Africa. 1-6th December
4. CODESRIA Bulletin, Special Issue 2, 3, & 4, 2003 Page 44.
5. CDC - Centers for Disease Control and Prevention. "Mother to Child HIV Transmission in Africa". Aids Action Council article. Jan. 2001. <http://www.thebody.com/aac/brochures/mothertochild.html>.
6. Singh, Susheela, Renee Samara. "Early Marriage Among Women In Developing Countries." Abstract. The Alan Guttmacher Institute. 1996. <http://www.agi-usa.org.pubs/journals/2214896.html>.
7. UNICEF. "Child Marriages Must Stop". Press Release. March 7, 2001. <http://www.unicef.org/newsline/01pr21.htm>.
8. Caldwell, J., Caldwell P. and Quiggins, P., 1989, 'The Social Context of Aids in Sub-Saharan Africa',
Population and Development Review, Vol. 15, No. 2, pp.185-234
*Mervat M. Mohamed is professor of biomedical research in the Human Reproductive Research Unit, and director of the research and training units, International Islamic Centre for Population Studies and Research (IICPSR), Al-Azhar University, Cairo, Egypt.
Download PDF version
[54Kb]
Back to main page
|
