Status of HIV/AIDS:
Epidemiology and Treatment

Of the 20 million who have AIDS in the world, 2.5 million of them are sub-Saharan Africans, according to the World Health Organization. "Africa has suffered the heaviest burden of diseases with less than 10% of the world's population, sub-Saharan Africa accounts for more than two-thirds of the estimated cases of AIDS worldwide and over 90% of cases in women and children." Approximately ten million people in Africa are infected by HIV. The area most highly affected by AIDS is called the "AIDS belt," which consists of four countries: Rwanda, Uganda, Zaire and Kenya. The earliest cases of individuals who have died of HIV-related illnesses were identified through tissue and fluid samples in studies throughout the 1980's. It was determined that a blood donor from Zaire in 1959 was one of the first known cases.

It has been suggested that disease epidemics generally explode during times of crisis. The economy has collapsed under the 32-year dictatorship of former-President Mobutu Sese Seko. The annual per capita income is less than $200. The wide disparities in wealth among the classes have left many families in Kinshasa eating only one meal a day leading to widespread malnutrition. AIDS, the biggest killer in Zaire, has been carried to even the most remote, road-linked settlement by long-distance truck drivers and soldiers. The military, in particular, is responsible for the spread of transmissible diseases, fulfilling their duties in a system where rape is a given. An estimated 40-60% of urban men are without waged employment.

Zaire exemplifies the social obstacles which must be overcome in the prevention and treatment of HIV/AIDS. The disease has affected all social classes but far from equally. Physicians and manual workers seen at a Kinshasa hospital were equally likely to be HIV-positive in 1984. In 1986, the prevalence among the manual workers doubled while the level had remained constant among the physicians. Trends like this have been amplified ten fold as major community based efforts are now being targeted towards those of low socio-economic status. The gender inequality in Zaire is also of such a great concern worldwide that it demands a more detailed exploration.

Women and HIV/AIDS in Zaire:
The deepening economic devestation is placing more and more Zairian women at risk of HIV infection. Because Zaire's recession is leaving many men without work and because an 8,500 percent annual inflation rate is undermining living standards, women of all ages have become prostitutes. Currently, Zaire's urban regions contain as many women as men yet women comprimise only 4% of formal sector workers. Those without job qualifications are forced to resort to informal-sector work such as: petty trade, food preparation, sewing, smuggling, and prostitution. The trade and smuggling take place over long distances within Zaire and across its borders. Multiple-partner sexual relationships are a very common part of these trade transactions. The worsening economic cris is contibuting to the feminization of poverty and the spread of AIDS. Researchers estimate that 7 percent to 8 percent of the general population and as much as 40 percent of prostitutes in Zaire are now HIV-infected. In a sample group of 1,000 prostitutes tested over a period of 30 months, 27 percent who were HIV-negative at the beginning of the study had become infected by the end. In Kinshasa, the rate among sex workers rose from 27% of 287 women sampled in 1984 to 35% of women attending a new screening clinic for STD's in 1988.

Case Study:
   Nsanga is 36 and very poor, the mother of a five-year old girl and a boy in primary school. Until recently, she contributed to the support of a younger brother in secondary school who lives with an elder brother. A younger sister also lives with Nsanga in a single room with a corrugated-iron roof, part of a block surrounding an open courtyard. The yard contains a shared water tap, a roofless bathing-stall and a latrine, but no electricity. In good weather, Nsanga moves her charcoal stove outdoors to cook.
   Nsanga wasn't always the head of her household. Village-raised, she married a schoolteacher in 1980, and managed somehow on his skimpy salary, despite galloping inflation of nearly 100 per cent each year. In 1983 the IMF instituted a series of 'structural adjustment' measures designed to reduce government expenditures so that Zaire, like other Third World nations which had borrowed heavily in the 1970s, could make payments on its international debt. More than 80,000 teachers and health workers were made redundant by this 'cleaning up' in 1984. Bringing health to the budget, this housecleaning has brought malnutrition and ill health to hundreds of thousands, including low-paid government employees, their families and those whom they formerly served. Many no longer have access to even minimal health care or education. Nsanga's husband was one of those who, lacking a powerful patron to intercede for him, joined the ranks of the unemployed. After six fruitless months of waiting in offices, he began to drink, selling off the household appliances to pay for beer and then lutuku, the cheap home-distilled alcohol.
   Nsanga tried many things to earn money. Like most poor women in Kinshasa, she has had only a few years of primary schooling. Since she has no powerful friends or relatives either, she was unable to find waged employment. She cooked food for neighborhood men, she sold uncooked rice in small quantities and dried fish when she could obtain supplies cheaply. These efforts brought in only pennies at a time. Her husband left and Nsanga does not know where he is. The children ate into her stocks and she went into debt for the rent. She asker her elder brother for a loan, but he refused, pleading poverty. Although he has a steady job as a labourer on the docks, he has two wives and nine children.
   Without her start-up capital, exchanging sex for substinence seemed the obvious solution. The first year she had a lover who made regular support payments. She also had a few occasional partners to meet occasional cash needs. Then she got pregnant and the regular lover left. His salary couldn't stretch that far, he told her. So Nsanga had to take on more partners. The neighbourhood rate was 50 cents per brief encounter in 1987 and Nsanga says that if she is lucky she can get two or three partners per working day, for a total of $30 a month (at most). Many men now avoid sex workers since the mass media have identified 'prostitutes" as a source of infection.
   Nsanga's baby was sickly and died before her second birthday, following prolonged fever, diarrhoea and skin eruptions. Nsanga believes it was because semen from so many men spoiled her milk. Nsanga reports that she has had a few bouts of gonorrhoea, for which she took some tetracycline pills on advice from the pharmacy clerk. About a year ago she had abdominal pains for several months, but no money to consult a doctor. She says that the European nuns at the dispensary in her neighborhood do not treat such diseases. Diagnosis at the nearby University clinic costs the equivalent of 30 encounters, so none of the women she knows can afford quality care.
   Asked about condoms, Nsanga said that she has heard of but never actually seen one. She has heard that men use them to prevent disease when they have sex with sex workers. Nsanga rejects this morally stigmatizing label, and if a lover were to propose using a condom, she would be angry. 'It would mean that he doesn't trust me.' In her own eyes, Nsanga is not a sex worker because she is not a 'bad woman.' On the contrary as a mother who has fallen on hard times through no fault of her own, she is trying to meet family obligations.
   Nsanga has become very thin and believes that people are whispering about her. In fact, her neighbors are sure Nsanga has AIDS, but then, Nsanga reasons: 'People say this about everyone who loses weight, even when it is just from hunger and worry. All these people who are dying nowadays, are they really all dying from AIDS?' Her defensiveness is shared by numerous women in similar circumstances.
                                                                         by Brooke Grundfest Schoepf(2)

**Prevention and Education:
Due to the efforts of governmental agencies and community based organizations, monthly condom sales in Kinshasa and elsewhere in Zaire have risen steeply. The bombardment of social marketing through media campaigns have increased awareness to the ubiquity of the epidemic. Through education, misconceptions are being cleared. It is believed that regular doses of semen are necessary to make a foetus grow. Condoms, with this belief, are seen as a blockage of this flow and are interpreted as a health risk. The large scale marketing campaign for condoms begain in 1989 offering a dozen condoms for half the cost of a bottle of beer. The solution has been a governemental large-scale campaign with the private sector handling the delievery of methods and the costs of subsidized services through modest charges.

**Treatment and Healing:
Most Africans go first to a traditional healer when they are ill. This important link has been generally ignored by the Western-oriented development agencies that are re-creating African health care systems in the image of European and American ones. With their direct access to the population, traditional practitioners can have an important role in education, prevention, and treatment. At the 7th International Conference on AIDS in Yaounde, Cameroon, attention was given to the possibilities of integration between traditional and biomedical health care. One traditional healer in specific was present at the conference to relate the theories and practicees of traditional healing. Fokoundang Adam Usamanu of Cameroon has been organizing approximately forty traditional healers in order to combine knowledge and resources to help AIDS patients.One of the treatments he uses is yohimbine, which in the United States is a prescription drug found in the bark of the Corynanthe johimbe tree and used for treating impotence in men. AIDS TREATMENT NEWS #159 (September 18, 1992) reported on the experiences of two people with HIV who had positive results using yohimbine for the treatment of fatigue. This coincidence suggests again that traditional healers have knowledge of useful treatments, many of which are unknown to western pharmacists. Fokoundang Adam Usumanu has 30 treatments that he currently employs. (Heyman, J.)

The practice of ritual scarification has comparatively been on the decline for 15 to 20 years. However, therapeutic scarification as treatment of localized pan and swelling, has been increasing. HIV infection has been correlated with scarification in one hospital study in Zaire. The joint efforts of traditional healers and Department of Health officials have been training and educating healers as to the risks and potential dangers of blood letting.


Community Based Organizations:
Society for Women and AIDS in Africa
Manoka Abib Thiam, Central Africa Coordinator
B.P. 1793
Kinshasa 1
Telex: (243-12) 21405

1. World Health Organization
2. Berer, M. (1993). Women and HIV/AIDS. London, England. Harper Collins.