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Social and cultural attitudes mean HIV has caught hold of Africa

In essence, HIV in Africa is exactly the same as HIV in the UK, United States, China and everywhere else. The virus is the same, as are the ways it is spread.

But Africa, in particular sub-Saharan Africa, is the area most heavily affected by the HIV epidemic. At the end of 2010, there were an estimated 22.9 million people living with HIV in sub-Saharan Africa.

So why has HIV been so much more devastating and widespread in Africa than in other regions of the world?

The answer to this question is still a matter of continuing debate. Suggested explanations include the subtypes of virus that are common in Africa, genetic factors and the biology of parasitic worm infections found in sub-Saharan Africa. But experts argue there are equally, if not more, important social and cultural factors that influence HIV transmission.

Dr Gitau Mbaru, senior adviser on HIV and health systems at the Aids Alliance, says understanding and overcoming social and cultural barriers around HIV infection is often the “missing link” when working to reduce HIV infection in African communities. “There have been tremendous advances made, but so far tackling social and cultural issues lags far behind. Culture and stigma are still barriers that are holding us back in Africa.

Gender imbalances and inequality in many African countries play a role in the spread of HIV

“A lot of the issues come down to stigma, both of the condition and of people living with it. The fear of finding out your HIV status comes from stigma, as people who are HIV-positive are often marginalised. This leads to lower uptake of HIV services, poor retention when people are receiving healthcare, and reduces the effectiveness and the efficiency of health systems.”

Luisa Orza, a trustee and co-chairwoman of the gender working group of the UK Consortium on Aids and International Development, says gender imbalances and inequality in many African countries play a role in the spread of HIV.

“Young women are among the most vulnerable to HIV in Africa, with rates of infection four to ten times that of their male peers. Young women often have very limited access to sexuality education, sexual and reproductive health services.”

Women are also expected to display modesty and appear to be less knowledgeable about sex than a male partner.

“This makes it hard for girls or young women to carry condoms or initiate conversations about condom use,” says Ms Orza. “In many parts of Africa there’s a lack of access to fertility choices, including family planning, emergency contraception and safe, voluntary abortion, which also puts girls and women at risk.”

But the increased risk among women is not limited to Africa, she says, adding: “HIV incidence among young women is increasing in every part of the world, including where prevalence rates are on the decline.”

Joseph Ochieng, editor of MAMBO, a healthy lifestyle magazine published by the Terrence Higgins Trust, says: “Black Africans are the second largest ethnic group affected by HIV in the UK. Five to ten years ago, cases of HIV were mostly ‘brought’ from Africa. But now the proportion is changing and people are increasingly getting infected in this country. So clearly people are still taking risks.”

Many misconceptions still exist among Africans in the UK, and the Trust’s campaigns emphasise condom use and HIV testing in African community. But the adherence to cultural beliefs can make this even more difficult, Mr Ochieng says.

“Some migrants still live according to their culture, some aspects of which predispose people to infection, such as living in a male-dominated culture that makes it difficult for a woman to insist her husband or partner uses a condom. This needs to be challenged. But it’s difficult, as Africans, even those living in the UK, are still very circumspect when it comes to talking about sex.”

This reticence also surrounds addressing HIV infection in black African homosexual men. “The potential for exposure to sexually transmitted infections and HIV in black African men who have sex with men is very high. The level of homophobia in the African community is just as high as back home in Africa; there are deep-rooted feelings and this makes it very difficult to tackle,” says Mr Ochieng.

Dr Mbaru is clear that only systemic change will address these issues, both in Africa and the UK. “We support community-based programmes that identify where the barriers are and challenge them. There needs to be structural, legal and health policy changes. The laws of the land have to change.”