Wednesday, June 1, 2011

Why Is There So Much HIV In Botswana?

As a caveat: this is strictly my opinion based on my personal experience and research. I am by no means an expert, much less a scientist.

If you Google “HIV rates in the world”, you might get a map of the world that is a patchwork of colors. Look closer and you will find that the southern Africa region is home to the highest rates of HIV in the world. In fact, if you look at the countries with the highest rates of HIV, 9 out of the top 10 are in southern Africa and all are in Africa. The continent has only 15% of the world’s population but has almost 90% of the HIV cases.

Botswana’s current HIV rate is somewhere between 20 and 25%, giving it the dubious position of the second highest in the world (only behind Swaziland).

The question “Why is there so much HIV in Botswana?” is deceptively simple with no simple answer. In short, people here contract HIV because they have unprotected sex with someone who is not their exclusive, life-long partner. While this fact is very true, it does little to explain the current epidemic. Many people in countries all over the world, including the United States, have unprotected sex with someone who is not their exclusive, life-long partner but it does not lead to high HIV rates. In fact, in the United States the HIV rate has never exceeded 1%.

So there must be something else that drives the epidemic here, but what exactly is it? I recently did an informal survey among the peer educators I work with and asked them to give me their opinion of why there is so much HIV in Botswana. The answers were all over the board but included causes such as poverty, ignorance, prostitution, low or incorrect condom use, and multiple partners.

The International HIV/AIDS charity Avert lists the causes as, “poverty, economic disparity, social instability, gender inequality, sexual violence, other sexually transmitted infections (which facilitate HIV transmission), lack of male circumcision, high mobility, rapid urbanization and modernization, and ineffective leadership during critical periods in the epidemic’s spread.

I think it is safe to say that the cause is quite complicated. The above issues definitely play a part in the spread of HIV, but taken individually, few can completely account for the epidemic. There are plenty of poor countries that have HIV rates below 1%. There are also many countries with lots of prostitution with low HIV rates. There are also many countries that have both very low condom use and low levels of HIV. So what makes these countries different from the ones in southern Africa?

A few issues stand out as most important to me and they form a "lethal cocktail". The region has very low levels of circumcision, high rates of STIs, and has the practice of multiple concurrent partners (MCP). (Interestingly enough, tribes in southern Africa practiced circumcision as part of a male rite of passage ceremony for centuries, but the practice was thought to be "barbaric" by early missionaries and was consequently stopped). Currently, the Government of Botswana is making a large push to get men to get circumcised.

MCP is particularly dangerous because HIV is highly contagious in the first 3 months of infection and can easily be passed on to many people in a sexual network. It is also deeply engrained in the culture. There is a phrase in Setswana that translates to, “A man cannot be contained to one kraal” (A kraal is a stable for cattle) and I have heard that there is no direct translation for the word “fidelity.” A recent study by the CDC in Botswana showed that up to 33% of men in Botswana engage in MCP, while it was around 25% for women. Studies also show that couples in long term relationships are less likely to use condoms than those who engage in casual sex, further exacerbating the problem.

In her book “The Invisible Cure,” epidemiologist Helen Epstein, theorizes that the main reason there is a much higher HIV rate in southern Africa than the rest of the world is primarily due to MCP and has the opinion that this cultural aspect is a direct driver of the disease (An opinion I absolutely agree with). She also shows that there is evidence that if you only lower the number of concurrent sexual patterns, the HIV rate will drop significantly. All you have to do is look at the ABC campaign in Uganda during the 1990's that stressed partner reduction and condom usage. This highly successful campaign resulted in a drop in the HIV rate while it was skyrocketing in most other African countries.

Western culture in general does not tolerate MCP and this is a major reason the rest of the world has been spared from HIV spreading through the general population. It is easy for a "westerner" to sit back and make moral judgments. There is a still a large problem with a morality based stigma associated with HIV. Because HIV is primarily caused by sex, and sex raises all sorts of moral and religious issues, it is easy (but incorrect) to think that a person with HIV has done something wrong. The problem with MCP is that it exposes a large number of people to the disease through vast sexual networks, especially if a person's partner is not completely faithful.
The causes of HIV in Africa, and especially in southern Africa, can seem quite complicated and difficult to change, but HIV remains a disease that is easily prevented. What remains to be seen is if people and governments have the willpower and the courage to motivate themselves and others to change their behaviors.