It's a tale of culture, geography, economics, colonial legacies, scientific advances, and now the idea that we have to prevent cases and treat patients one at a time
A child takes part in a World AIDS Day event in Cape Town, South Africa / Reuters
Sub-Saharan Africa only has 12.5 percent of the world's population but, last year, 70 percent of its new HIV infections (1.9 out of 2.7 million) and 67 percent of its AIDS-related deaths (1.2 out of 1.8 million). Two in three HIV-positive people live in Sub-Saharan African (22.9 out of 34 million). Of the approximately 250,000 children under age 15 who died of AIDS-related causes last year, 90 percent were Sub-Saharan African.
Today, as this year's UN World AIDS Day report emphasizes, the global fight against AIDS focuses overwhelmingly on Sub-Saharan Africa, where it is making real progress. Since 1997 -- the peak of the world AIDS crisis -- the number of new HIV infections has dropped 21 percent worldwide and 26 percent in Sub-Saharan Africa. The number of new HIV infections globally has leveled off in recent years, but the worst afflicted countries are doing better at slowing the virus's spread, which bodes well for reducing infection rates in the future. In the meantime until we get to global zero, we're getting better at treatment: the number of AIDS-related deaths is still dropping as treatment improves in poor or remote communities.
Factors like poverty and education play a role in Africa's AIDS epidemic, but it's more than that. A Sub-Saharan African is still five times as likely to have HIV as likely as someone from the Caribbean, the region with the second highest prevalence rate; 12 times as likely as a Latin American; 17 times as a South or Southeast Asian; and 25 times as a Middle Easterner or North African. The AIDS crisis is global, but it is in many ways an African story. The more people in a given community are infected the more likely than a healthy member of that community will in turn be infected, which is part of what makes Africa's crisis so hard to turn back.
The story of how Africa's AIDS crisis came to be is complicated, controversial, and almost as heavily debated as what to do about it. Since rushing to the continent en masse in the 1990s, researchers have theorized one potential cause after another -- physiology, marriage culture, food practices, poor governance, and on -- all of them backed up by data and many of them convincing. It can be hard to resist the idea that Africa's problem is that it is very unlucky. But there's nothing inherent to Africa that means prevention and treatment can't succeed in rolling back the AIDS crisis, as they already are.
For years, research on Africa's AIDS crisis focused on the behavior of Africans, which has been controversial. Well-meaning scientists, often from the same white European countries that ravaged Africa through colonialism only a century earlier, have struggled to break out of the same stereotypes that enabled and exacerbated the worst colonial practices. Researching AIDS in Africa can be most fraught when it comes to the one human behavior that's perhaps most relevant to the disease but the touchiest to talk about in this or any culture: sex. How, when, and where people have sex can, unsurprisingly, play an enormous role in their exposure to sexually transmitted diseases like HIV. And sexual practices can be enormously cultural.
So it's natural to wonder how or whether African cultural particulars relating to sex might play a role in how AIDS is transmitted there. But that's been a difficult subject for the Westerners who dominate HIV research to bring up in Sub-Saharan Africa. European obsessions with African sexuality persisted right up until the end of the colonial era, which, it's easy to forget, lasted well into many of our grandparents' lifetimes. It wasn't so long ago that Europeans were carving up African genitals for display in museums or lining up for "primitivist" dance performances in black-tie concert halls.
This isn't to say that Western scientists are racist, of course, but it hasn't been easy for them to study African sexual culture without being affected by centuries-old Western stereotypes about Africans. A 2003 paper in Development and Change found, "Western preconceptions regarding African sexuality distorted early research on the social context of AIDS in Africa and limited the scope of preventive policies. Key works cited repeatedly in the social science and policy literature constructed a hypersexualized pan-African culture as the main reason for the high prevalence of HIV in sub-Saharan Africa."
Still, culture influences behavior and behavior influences health. So culture needs to be studied to understand HIV, but as any anthropologist will tell, you can't study someone else's culture without understanding your own and the biases that it gives you. Western AIDS researchers in Africa have a hard job: not only do they have to understand one of the worst health crises since the black plague, they also have to understand how centuries of European-African interactions color their own perception of African culture.
In 1989, the Journal of Health and Social Behavior published a study on how Sub-Saharan Africa's migratory labor economy made it easier for HIV to spread and harder for it to be prevented. African economies' heavy reliance on shifting migrant labor created "long absences, increased family breakdown, and increased numbers of sexual partners." A 1993 New Yorker story focused on the role of truckers in Central Africa, where HIV first spread to humans. Geography and poor governance make Central African infrastructure some of the weakest in the world, which means that truckers are unusually numerous there. Trucking and prostitution typically coincide; the proliferation of the former could likely promote the latter. Because HIV may have spread to humans in Central Africa up to a century before the disease was first studied, it had plenty of time to entrench itself in the group of Africans most likely to transfer the disease.