Scientific American CARE FOR A DYING CONTINENT In Zimbabwe--where AIDS is prematurely killing a generation of adults--counselors and researchers struggle against social customs, viral resourcefulness and despair. By Carol Ezzell, staff writer Photographs: Karin Retief/Trace Images/The Image Works "If the younger generation does not change, we are going to perish." Millicent Tigere perches expectantly on the edge of the sofa, her hands folded in the lap of her simple black skirt. At the age of 20, she has already been married for two years and has a one-year-old baby girl, now strapped to her back with a white terrycloth towel. One of her relatives died a year ago, and she suspects the cause was AIDS. She has come to the clinic today to find out if she herself has a future--or if her child is destined to become an orphan like the estimated 10 million others on the continent of Africa. Millicent lives in a town on the outskirts of Harare, the capital city of the southern African nation of Zimbabwe. Her husband, who is 26, has a job as a bank teller--a feat, considering the country's unemployment rate of roughly 50 percent. Millicent speaks a little English, which is Zimbabwe's official language, but she prefers to conduct her AIDS counseling session primarily in Shona, her tribal tongue. Chiratidzo Muyaka, Millicent's counselor, is a motherly figure in her 40s with glasses and big brown eyes. Her past experience as a schoolteacher shows as she guides Millicent through the "pretest" questionnaire that will prepare her for her blood test for the human immunodeficiency virus (HIV), the cause of AIDS. Does she know how the AIDS virus is spread? Millicent confidently and correctly identifies unprotected sex, sharing hypodermic needles and childbirth as the major means through which HIV is transmitted. THE GOMBEDZAS Has she had sex with anyone other than her husband? She shakes her head no. Has her husband had sex with other women? "I don't think so," she answers, laughing nervously behind her hand. Has she thought about what might happen if she tests positive? Her smile fades. She pauses to reach back and pull up one of her sleeping baby's flower-patterned socks before answering. "I get worried if I am positive, because I would be divorced [by my husband], and I worry about breast-feeding." Nevertheless, she declares, she plans to share the results of her test with her husband. Although she says she and her husband have never used condoms because she takes birth-control pills, Millicent agrees to discuss condom use with him before she returns in two weeks to receive the results of her HIV test. She takes a dozen free condoms because, she says, she and her spouse have sex nearly every night. Then she leaves the counseling room for the clinic's examining room to have her blood sample drawn. The chances that Millicent is not already infected with HIV are not good. Zimbabwe's National AIDS Coordination Program (NACP) estimates that between 20 and 25 percent of the population carries the virus. The likelihood that one in every four people I meet is infected with HIV haunts me as I walk the streets of Harare. The face of HIV is everywhere: on the taxi driver who drove me to my first appointment this morning, on my waiter last night, on the woman selling roasted corn on the cob at the side of the road, on the businessman emerging from his Mercedes. I have come to Zimbabwe because it represents one of the best of the worst. As in other sub-Saharan African nations, the AIDS problem here is so severe that it eclipses the often-used term "crisis." AIDS is destined to alter history in Africa--and, in fact, the world--to a degree not seen in humanity's past since the Black Death. But unlike some other African countries, Zimbabwe is not riven by tribal violence. If any behavioral intervention against AIDS will work in Africa, one of its best chances will be here. But that one-in-four estimate of Zimbabweans infected with HIV is likely to be optimistic, based on scanty data and wishful thinking. The statistic derives from blood samples collected periodically from pregnant women who show up at a dozen maternity clinics around the country--a system that even Evaristo Marowa, director of the NACP, acknowledges is inaccurate. Workers at the clinic to which Millicent has come see HIV infection rates that are much higher. Nearly 40 percent of the women presenting themselves for HIV counseling and testing have turned up positive, according to epidemiologist Nancy S. Padian of the University of California at San Francisco. Padian is collaborating with Z. Michael Chirenje, Tsungai Chipato and Michael T. Mbizvo of the University of Zimbabwe's department of obstetrics and gynecology on studies to find ways to prevent the spread of HIV, which in Africa is transmitted largely through heterosexual sex and from mother to newborn. Like many other AIDS researchers, they are focusing on women instead of men in part because women are familiar with attending clinics during pregnancy and to obtain birth control. Their research targets reproductive-age women who are not yet infected; their goal is to keep the women and their families that way. Because volunteers for the trials--who will number more than 10,000--must be screened for HIV, the researchers are also gathering some of the most reliable data on the true incidence of HIV infection in Zimbabwe, which is thought to be typical of southern Africa. But for many women it is already too late. The particulars of each who comes to the clinic are recorded in a large ledger. When the results of the confidential HIV tests come back, the negative ones are entered in black ink and the positive ones in red. On many of the ledger's pages, the red ink overwhelms the black. In the Society of AIDS If HIV were a thinking creature capable of designing the optimum conditions in which to thrive, it couldn't have devised a better situation than Zimbabwe--and, indeed, most of Africa. Leaving aside the poverty and lack of general medical care caused by rampant inflation and joblessness, Zimbabwean culture has other vulnerabilities that HIV can exploit. First, it is a male-dominated society with a history of polygamy, where even today the characters of popular comic strips make jokes about which wife they might be staying with on a given night. Second, as in many other African countries, many Zimbabwean men come to the cities to find work, leaving their wives and children in the rural areas to which they will return only two or three times per month, according to Chiedza Musengezi, director of the Women and AIDS Support Network (WASN). While in the city, men sometimes visit prostitutes or have girlfriends, each of whom might have several men contributing to her upkeep: one who pays the rent, one who buys groceries and so on. And some of the wives left behind occasionally sell sex, too, especially right before their children's school fees come due. During a ride through Harare one day, Rudolph, a taxi driver with a wife and seven children in one of the rural areas, tells me that most of his friends have girlfriends or so-called customary wives in town. "Some say the best thing is to [have other women and] use condoms," he says. But Rudolph, who declines to give his surname, has had a brother, a niece and a nephew die of AIDS. "I don't want to deal with other women; I just stick to my wife only," he says. "If it has been a long time, I go to see my wife. I like to control myself and have my wife take the duty [of sex]." It is hard to tell whether people like Rudolph and Millicent are even telling the truth; people everywhere sometimes lie about their sexual behavior. When I ask Prisca Nyamapfeni--the nurse who manages the clinic where the studies headed by Chirenje, Chipato and Padian are run--whether they see many prostitutes or girlfriends, she answers that it's hard to tell. "Girlfriend" relationships can last for years, and the women usually call themselves wives. And no woman is likely to admit freely that she sells sex when desperate for money, according to Nyamapfeni. "All women say they have had one [sex] partner in the last three months," she remarks. Sexual and hygienic practices in southern Africa also contribute to the high rate of infection. It is not uncommon for women to use their fingers, cloth, paper or cotton wool to swab the vaginal walls immediately before and during intercourse to achieve so-called dry sex, which is favored by many men. Some women also insert detergents and substances obtained from traditional healers--such as herbs and, rarely, soil on which a baboon has urinated--to induce an inflammatory reaction that dries, warms and tightens the vagina. In the February issue of the Journal of Infectious Diseases, Janneke H.H.M. van de Wijgert--who is now at the Population Council in New York City--Chirenje, Padian and their colleagues reported findings that women who use such intravaginal practices were more likely than nonusers to have disrupted the normal balance of healthy bacteria in their vaginas. Such disruptions are known to make the vagina more susceptible to sexually transmitted infections. Dry sex also works in HIV's favor because it increases the likelihood that condoms will break. In addition, it causes microtears in the vaginal walls through which HIV can gain faster access to the bloodstream. WAREHOUSE Chirenje, a charming man who chairs the department of obstetrics and gynecology, tells me it is difficult to state the proportion of women who use intravaginal practices. "They are shy to discuss it, but it is probably a quarter to a third," he suggests. Indeed, a recent survey--called the Voices and Choices Project--of 200 HIV-positive women in Zimbabwe indicates that the percentage could be higher. The leader of the survey, Caroline Maposhere of the International Council of Women, found that 50 percent of the women she studied wash out their vaginas with soap and water before sex. Another 20 percent douche with household detergent, and 17 percent insert herbs. "They all use something," Maposhere says. I am shocked when she tells me that fully 67 percent report pain during sex. Half of those who have painful sex have a sexually transmitted disease or pelvic inflammatory disease, which can result from repeated bouts of venereal disease; the other half attribute their discomfort to being forced by their partners or to using herbs in order to achieve dry sex. If adult women have a difficult time lowering their risk for HIV infection, it is even tougher for young women because of the "sugar daddy" phenomenon: older men with money who look to teenage girls for sex. Young women are particularly dazzled by men who have what they refer to with their friends as "the three C's": a car, a cell phone and cash. But many of them go with sugar daddies for a far more desperate reason: money given to girls by sugar daddies is sometimes an important source of family income. The men know that the girls are less likely to have had sex--and encountered HIV--than older women. Some also believe that having sex with a virgin can cure them of HIV infection or AIDS. The HIV infection rate among 15- to 20-year-old girls is five times that of boys the same age, according to WASN's Musengezi, which indicates that the young women must be getting HIV from older men. The male condom is the best-known means of stemming the spread of HIV, but negotiating condom use is tricky for most Zimbabwean women, particularly wives. It's not just a matter of coming home with a handful of condoms and asking their husbands to use them. "If a wife comes to me with an idea, it is downsizing me," explains Eliot, a 40-year-old AIDS counselor who himself has the disease. Men "get angry," he says, because if a wife suggests something, it implies that the man should have thought of it first. Husbands also resent being asked to use condoms by a wife because they have often paid lobola, or a bride price, for them. Between a Rock and a Thin Layer of Latex So far roughly half the women who have entered the condom acceptability study being conducted by Chirenje and Padian--which is funded by the U.S. Centers for Disease Control and Prevention--have been able to get their husbands to use condoms, in part because counselors such as Muyaka work with the women to devise "scripts" that they can use to convince their partners. They even demonstrate the proper way to use a male condom on a wooden model of an erect penis that is kept under a cloth drape. But this can be a shock, because most women are not used to seeing a depiction of an aroused penis. "More than one lady has jumped back when we showed them the penis model," Lisa Loeb, project coordinator for the study, recounts to me. "They say, �My husband doesn't look like that!' " If a woman still can't convince her partner to use a male condom, on a subsequent visit to the clinic she is offered other options, such as female condoms, which she is shown how to use on a plastic dummy of a female vulva and vagina. A female condom is essentially a plastic sheath with two flexible plastic rings at either end. The smaller ring, which is at the closed end of the sheath, is inserted over the cervix so that the sheath lines the vaginal walls. The open end of the sheath and the larger ring remain outside the body. Although the final data are not yet in, the female condom "hasn't really taken off yet as we hoped it would," comments Gertrude Khumalo-Sakutukwa, the senior social scientist for the University of California/University of Zimbabwe collaboration. She says many women dislike the female condom, which the clinic offers free, because they claim it's ugly and unnatural and can squeak during sex. The female condom is also expensive. The British government donates most of Zimbabwe's male condoms, which are relatively cheap to produce and can be obtained free from any clinic or for a negligible price from all kinds of shops under a subsidized marketing program. In contrast, few clinics can afford to provide free female condoms, although the aid organization Population Services International has begun underwriting a program to sell packages of two female condoms for less than 10 cents U.S. Marowa of the National AIDS Coordination Program says that his office is "promoting both" male and female condoms. So far, though, he asserts that the male condom is more acceptable than the female one. PROSTITUTES Whether the man or the woman wears the condom, family and sexual politics complicate the issue of condom use. If a wife asks her husband to wear a male condom, says Eliot, he might take it as an accusation of infidelity. Similarly, some men think that wives who have access to male or female condoms are more likely to sleep around. The decision to use condoms also adds another layer of complexity to the decision of when--and even whether--to have children. Mothers-in-law sometimes pressure wives to bear many children to enlarge the extended family. How can a daughter-in-law say she doesn't trust her husband enough to stop using a condom so that they can conceive? Telling her partner that she is HIV-positive may have even more serious ramifications. Out of every 10 women who test positive, Muyaka estimates, six are initially afraid to tell their husbands. She doesn't know how many women have been dumped by their husbands. Two have come back saying they were beaten. Offering Hope By the time our car pulls into the parking lot of the clinic on the grounds of Harare Central Hospital at 8 A.M., the women are already there: sitting in the shade of the tree or perched on the cement steps, many with babies on their backs. Most have risen before dawn and have either walked to the clinic or have taken "emergency taxis"--unlicensed minivans that are operated by men who charge the equivalent of less than one U.S. dollar to bring people into the city from the outlying "high-density suburbs," the politically correct term for the former black townships. Our car, which belongs to the clinic's research program, isn't much better: it's an ancient Peugeot with no inside door handles and only one window handle--and even that usually bangs around like a spare tool on the dirty floorboard. To get out, we have to find the loose window handle, reattach it, roll down the window and reach out to open the door from the outside. But all the clinic's staff are in high spirits today. Project coordinators Tinofa Mutevedzi and Joelle Brown have just found out that the preparation of nonoxynol-9 gel that they hope to offer as a backup method for protection against HIV to women who cannot consistently use condoms has been approved. And today is the first day of a dry run to work out any kinks in the procedures for a huge upcoming study of whether using hormone-based contraceptives such as the birth-control pill and Depo-Provera injections--the most popular forms of birth control in Zimbabwe--make a woman more susceptible to the AIDS virus. Chirenje, who initially established the clinic where the AIDS studies are being conducted, is a proponent of microbicides such as the nonoxynol-9 gel, particularly for women who cannot negotiate condom use. In a previous study, Wijgert, Chirenje and their colleagues found that another preparation, called BufferGel, was "quite acceptable" to women and their partners, although some of the men at first expressed concerns that the gel would lead to wet sex. Chirenje, Chipato and Padian have high hopes for the nonoxynol-9 gel. Their gel study, which is funded by an international organization called HIVNET, will include at least 4,440 women not infected with HIV and will involve the Zimbabwe clinic as well as two clinics in the nearby country of Malawi. Women will be tested for HIV every three months for three years to see how well the gel protects them against infection. Padian, a small, driven woman with blond hair and glasses, says she and Chipato are particularly interested in approaches that protect the cervix, which they suspect is the part of the female reproductive tract most susceptible to infection by HIV. "The study I've been wanting to do for years is to see if protecting the cervix will protect against infection," Padian declares. She is eager to do a clinical trial of diaphragms and cervical caps. "Some people think women won't use the diaphragm," she says. "But if they're willing to use the female condom, they should be willing to use a diaphragm." She cites studies showing that diaphragms protect against chlamydia and gonorrhea, which are known to target the cervix, as well as evidence that HIV is shed more frequently from the cervix of infected women than from the vaginal walls. But she concedes that some researchers have found that women who have had complete hysterectomies, which remove the cervix, have still contracted HIV. For now, however, the hormone study--part of a multinational HIVNET effort also involving Uganda and Thailand--will be occupying Padian's time. Project coordinators Angella Muchini and Megan Dunbar will be screening thousands of women from the Zimbabwe clinic to find 1,490 who are not infected with HIV; the total number of HIV-free women at all of the study sites will be 6,360. One third of the women will be taking oral contraceptives, one third will receive contraceptive injections, and the rest will use nonhormonal forms of contraception. All the women will be given free male condoms, which, they will be counseled, are currently the best protection against HIV. At the end of three years, researchers at all the sites will see if the women who took the hormone-based contraceptives had a higher rate of HIV infection. This will be the first study to test the association in a statistically rigorous, straightforward manner. Exactly how hormones might make a woman more susceptible to infection is not yet clear, but the drugs are known to increase the number of epithelial cells in and near the cervix that are column-shaped. Padian speculates that HIV is better able to squeeze between the cells of the columnar epithelium than to wriggle through the layers of flat, squamous epithelial cells that line most of the vagina. In contrast, it is also possible that hormones might help protect women from HIV infection because they are known to thicken the cervical mucus, which might form a barrier to the virus. HELPING HANDS Finding the answers to such questions may take years. In the meantime, a host of organizations are trying to change the behaviors of people in Zimbabwe, particularly those of the young. Barbara D. Chakanyuka, national youth program officer for the YWCA in Zimbabwe, runs a nationwide peer-counseling program for teenage girls. "We stress abstinence, but we also give them information on condoms," Chakanyuka says. Lillian Savadye of the support organization AIDS Counseling Trust states that women are especially receptive to learning how to reduce their risks of infection. But learning isn't enough. "People are well informed, but the aspect of behavior change needs to be worked on," she asserts. "They know the risks, but they don't have the push to ask themselves to change their behaviors." Why people don't do things they know are good for them is a universal conundrum, but one with deadly consequences in the wake of HIV. Nyamapfeni, the nurse who manages the Harare clinic I visited, tells me she has yet to hear of a client who says that she and her partner have ever used a male condom specifically for AIDS prevention. Nyamapfeni, an elegant woman who favors feminine blouses and smart suits beneath her crisp white lab coat, has seen the disconnect between knowledge and behavior close to home. Her sister and brother-in-law died of AIDS a few years ago, and she and her husband and the rest of her extended family are sharing responsibility for the four orphans left behind, aged four through 18. When I ask her what she thinks her country will look like in 20 years, she replies solemnly, "I think there are going to be very few people." If she were in charge of Zimbabwe's AIDS intervention efforts, she says, one of the first things she would address would be to find out why the ubiquitous AIDS education programs are having so little effect. "We are taking too long to change our behavior," Nyamapfeni comments sadly. "We are still under a lot of denial." THE PAUKA FAMILY Chipato--Padian and Chirenje's research partner--also fears for the future of his country. "Fifteen years from now it is going to be a very young population" in Zimbabwe, predicts the quiet 42-year-old with the disarming gaze. "Most of my contemporaries are dying out." The urgency of the problem has prompted some people to propose drastic actions. Maimgehama Taderera, who leads the local chapter of an orphan organization called the Child Survival Project outside Harare, advocates rounding up all the HIV-positive people and keeping them in special villages separate from those who are not infected. Taderera knows about detainment: he was imprisoned for six years for political activities and was then under house arrest for many more years; torture by his captors left him with a limp. "If the younger generation does not change, we are going to perish," he warns. Others back less draconian plans. Ann Klofkorn, executive secretary of the Zimbabwe AIDS Network, applauds the recent formation by the government of a National AIDS Council to coordinate all aspects of HIV and AIDS. The current NACP is impotent, she claims, because it has purview over only the health ministry. Helen Jackson, executive director of the Southern Africa AIDS Information Dissemination Service (SAfAIDS), agrees. "AIDS is a development issue and should be treated as such," she asserts. Her organization also lobbied for the creation of the National AIDS Council, which so far has a budget of $8 million. "We've got money for the war [in the Democratic Republic of Congo, where Zimbabwe is supporting Laurent Kabila]," she says. "A lot of us would rather see the money spent on health, including AIDS [programs]." Maposhere of the International Council of Women sees the presidential elections in Zimbabwe, which are now scheduled for 2002, as an avenue of possible change. Robert Mugabe, who has been president since Zimbabwe's independence from Britain in 1980, has yet to declare AIDS a national emergency. "There should be more political treatment of HIV/AIDS, with resources," Maposhere contends. "If it's declared a national disaster, the money will come." Money isn't everything, but it certainly would help. According to a report prepared in July 1998 by the NACP and the Ministry of Health and Child Welfare--of which the NACP is a part--the annual budget of the entire ministry is expected to total only $54 million this year. Marowa declined to tell me the amount of the NACP's annual budget, but he did say that only 20 percent of it derives from the Zimbabwean treasury. The rest comes from foreign agencies and donors. The U.S., for example, has spent roughly $2 million a year on AIDS-related issues in Zimbabwe since 1989, according to William B. Martin, a program officer in Zimbabwe for the U.S. Agency for International Development (USAID). DANCING CLUB With such meager funds, the life-prolonging AIDS drugs available to many in the developed world--which cost upward of $10,000 per person per year--are unthinkable for the majority of Zimbabweans. What is left is behavior modification, which for now means condoms. Even with its difficulties surrounding condom use, Zimbabwe seems to be the African country that has gotten the message of the importance of condom use best. Patrick L. Osewe, program director for HIV/AIDS in USAID's Zimbabwe mission, says the Zimbabwe National Family Planning Council distributes 50 million male condoms a year, "the highest number on the [African] continent." That's roughly four condoms per year for every person in Zimbabwe. As I leave, I wonder about the outcome of Millicent's AIDS test and whether, if she tests negative, she will be one of the fortunate ones who will be able to use condoms consistently to protect themselves. Even if it is too late for Millicent, I can only hope that her daughter is uninfected and can grow up empowered enough to keep herself that way--even if she becomes an orphan. As Jackson of SAfAIDS said: "The thing that mustn't happen is saying the situation is so bad there's nothing they can do." ---------------------------------------------------------------------------- ---- Related Links: For more information on organizations mentioned in this article, visit www.sciam.com/2000/0500issue/AIDS.html ---------------------------------------------------------------------------- ---- <A HREF="http://www.ctrl.org/">www.ctrl.org</A> DECLARATION & DISCLAIMER ========== CTRL is a discussion & informational exchange list. Proselytizing propagandic screeds are unwelcomed. Substance�not soap-boxing�please! These are sordid matters and 'conspiracy theory'�with its many half-truths, misdirections and outright frauds�is used politically by different groups with major and minor effects spread throughout the spectrum of time and thought. That being said, CTRL gives no endorsement to the validity of posts, and always suggests to readers; be wary of what you read. 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