International Policy Issue - AIDS and HIV in Africa - Essay Example

Running head: Aids in Africa Aids in Africa [The name of the writer appears here] [The name of institution appears here] Introduction HIV is one source of crisis and suffering among many that desperately call for attention. Even in a middle income community in Europe or the United States where people expect to live to old age and cure what diseases they may contract, HIV battles for center stage with other life-threatening diseases. Social movements have been organized to combat patterns of discrimination and stigma associated with the disease and to convince national policy makers and health care providers of the hazard and the enormity of the suffering caused by HIV infection. Even in communities where treatment is insured and comfortable lifestyles affordable, debates concerning the distribution of funds for research and treatment, and the usefulness of early testing and diagnosis and its impact on the quality of daily life, have constituted an ongoing discussion (Angell, 1997). In the poorer countries of the world as indeed in poor areas of the United States, the dilemmas of making choices as to the allocation of scarce resources is more extreme. Should HIV take priority over other infectious diseases? Where should these resources come from and who should receive them? If prevention is the only feasible strategy, should funding be devoted to the prevention of HIV alone or to general public health and community health education efforts? Anthropologists and public health researchers and policy makers have to make hard choices. They have to balance their convictions against the requirements of the situation. Poverty and social disruption force us to evaluate moral issues within a different frame. Questions which appear to lead to one answer in the United States may generate contrasting responses in other situations. Consider simply whether to recommend that a young mother with possible symptoms should be encouraged to seek an HIV test. The Joint United Nation’s Program on HIV/AIDS’ (UNAIDS) charts the AIDS epidemic internationally. It documents its scale and sternness in Africa and the way in which that continent’s population has excessively borne its brunt. on the whole, by the end of the year 1999 it was estimated that 24.5 million people were living with HIV/AIDS on the African continent (UNAIDS, 2000). The prototype of difficulty varies, with those countries in eastern and southern Africa most affected (UNAIDS, 1998. 1 nonetheless, the overall rate of adult occurrence for the continent, at an estimated 8 per cent, is far, far higher than that of any other region of the globe, the next closest being the Caribbean at 1.96 per cent (UNAIDS, 1998). That AIDS has gained so tight a grip on a number of African countries is partially a result of their poverty, as symbolized by deficiencies in nutrition, hazards of living, and lack of access to medical care. In several cases, national indebtedness as well as regimes of structural adjustment has worsened difficulties of securing livelihoods and restricted access to health services, further adding to broad risk ecology in respect of AIDS. The very nature of the (indistinct) development they have experienced has figured in the spread and entrenchment of HIV/AIDS in these countries. Through its impact on output and the costs it involves, the epidemic is operating sequentially to aggravate further developmental progress, so much so that it has been belatedly recognized by international institutions to be the leading development concern for the present and predictable future. In the Kilimanjaro area of Tanzania, AIDS has been professed by many as being bound up with a ‘gradually emerging cultural crisis—a crisis rooted in transformations that began before the turn of the century’ (Jordan, Theresa, 1985). Ideas concerning sex and work—reproduction as well as production—have been created in concurrence with changing opportunities and new discourses, chiefly in the lives of youth, who, in seizing upon them and apparently discarding behaviors as well as practices which were previously valued, have been both vilified and placed in positions of greater vulnerability in respect of AIDS. Their elders in turn have seen youths’ vulnerability to HIV as justification of their own anxiety concerning the obvious abandonment of those former customs which had offered the social cement for the community’s very survival. In this sense, AIDS has produced a similar unease with changing norms of sexual behaviour— although attached to different specific practices—as took place in the North. All are potentially vulnerable to AIDS. HIV crosses all lines of social division. At the same time social conditions may involve particular vulnerability. Gender relations serve in this regard as a significant constituent of the way AIDS has impacted on African societies. While there is a considerable problem of parent to child transmission in several countries, and some transmission via blood and between gay men, by the far the most important form of transmission is through heterosexual encounters. Relative proportions of adult males as well as females infected differ from place to place, but UNAIDS has projected that by the end of the century, twelve or thirteen women were being infected in Africa for every ten men (UNAIDS, 1998). Partially since those infected at an earlier age may live longer with HIV, there may be escalating inequality in prevalence rates for males and females. Nonetheless, differentials also reflect disproportionate risk to women. In Ndola, on Zambia’s Copperbelt, for instance, adult occurrence was 32% for females as against 23 per cent for males in the late 1990s and in Kisumu, Kenya, correspondingly, 30 and 20 per cent (UNAIDS, 1998). In accounting for these outlines, it is necessary to recognize both how gender relations create vulnerabilities and the definite way the epidemic has impacted on women. Early on in the epidemic, the experience of men served to describe the range of offering symptoms and the course of the illness, so that women disappeared, certainly were not even in the picture. If the early association of HIV, not just with homosexuality, but also with the use of injecting drug use, led to a delay in the acknowledgment of a new illness circumstance by medics in Africa, it also led to a delayed understanding of its impact on women. But even when women were taken into account, it was characteristically via discourses of blame. They have typically been viewed as responsible for transmitting the virus, whether as prostitutes infecting their clients or mothers infecting their children, along lines of women being treated variously as vaginas or uteruses, as whores or mothers and, more kindly as vectors or vessels. Blame is most constantly and vigorously attached to those women regarded as accountable for the rapid spread of AIDS in Africa in their faculty as sex workers. But a wide brush of disapproval has frequently been extended to women generally as being responsible for AIDS. Also, in Africa as elsewhere, it is women who are liable for the birth of a child with HIV, as “impure vessels bearing condemned babies”.. Many writers have expressively as well as compellingly made the case for bringing women into the picture with regard to HIV/AIDS, particularly where heterosexual transmission predominates, not as responsible but as inhabiting a background in which they are frequently extremely vulnerable to infection. In acknowledgment of the escalating number of women affected and the way the burden of care falls on women’s shoulders at both family and community level. Nonetheless, if women have consequently come onto AIDS programs, it has debatably been to a lesser extent than need implies. Many women with HIV lack support and persist to be efficiently silenced, not least by virtue of the marginalisation which increases their likelihood of being infected. But significant shifts have taken place in discourses around women and AIDS during the course of the epidemic’s history. Under the sponsorship of the Global Program on AIDS (GPA), and later UNAIDS, early concern to counter discrimination against those with AIDS has been distorted into a more complete human rights approach which posits that the very marginalization of particular groups, as materialized in their lack of rights and the inequalities telling their circumstances, has restricted their capability to guard themselves. By insisting that women’s rights are unavoidably human rights and at least in theory generally appropriate, then particular factors, be they cultural conventions or structural inequality, can be cited as obstruction to protection requiring attention within a worldwide, moral framework. Women’s vulnerability to AIDS follows from social, but also physiological features. All else being equal, the likelihood of male to female transmission is projected to be two to four times that of female to male transmission (UNAIDS, 1997). The reasons are higher concentrations of HIV in semen than in vaginal fluid, a larger area of exposed female than male genital surface area, greater permeability of the mucous membranes of the vagina compared with those of the penis, and longer period of exposure of semen within the vaginal tract. Untreated sexually treated diseases (STDs) can boost the likelihood of HIV transmission in both men and women by as much as ten times (UNAIDS, 1997). Nonetheless, since STDs in women are frequently asymptomatic, they are less expected to be treated. Behavioral factors make the situation difficult, with women usually having poorer access to STD care due to distance, costs, sufficiency of facilities and the way the stigmatising nature of the situation deters them from seeking formal assistance. Increasing attention has been given to the importance of genital ulcer disease (chancroid), which is chiefly common in some African contexts and strongly linked with increased risk of HIV infection. Additionally, repeated infections of gonorrhoea, chlamydia and other reproductive tract infections, through their connection with infertility, can on occasion lead women toward greater sexual activity in an effort to conceive, or, in contributing to the forced ending of marriage, can result in women being placed at bigger risk of HIV. HIV itself has a direct impact in reducing fertility. When a woman who is already infected becomes pregnant, nonetheless, the progression of HIV may be accelerated and complications of pregnancy and delivery increased. While physiological factors augment the risk of transmission to women from unprotected sex and hasten the course of illness in a woman who is living with HIV, women’s social location can also place them in the environment of risk or slow down their ability to defend themselves. In large measure, women’s vulnerability to HIV infection derives from their low position in society. Similarly, women are portrayed as a ‘subordinate sector’, in referring to their low position as well as powerlessness in connection with AIDS. Powerlessness is a recurrent theme. Tthe key to understanding the foundation of women’s vulnerability. The background, substance and character (or specificity) of such powerlessness varies, instead describing either a universal failure in women’s capacity to secure their needs or their specific incapability to make sure protection within sexual encounters. It is in particular the link between control over potentially risky sexual relations and women’s position within the wider society that is vital, nonetheless, for an understanding of vulnerability and the way in which HIV moves through a population. Women often have too little power within their relationships to persist on condom use, and they have too little power outside of these relationships to abandon relationships that put them in danger’. Comprehending this relationship necessitates a preliminary examination, on one hand, of gender relations within the public sphere which conclude women’s ability to realize capabilities and accomplish a ‘good life’ and, on the other, power and control in intimate social systems The scale as well as depth of the AIDS crisis has encouraged calls to enlist women’s organizing capabilities and collective energy in campaigns for protection. Women have been targeted partially since they themselves have lined up to help as primary carers within families, through religious groups offering consideration to those who are sick or bereaved, via informal networks offering mutual support around rites of passage, and through more formal charitable and service organizations, NGOs and community-based organizations. While men are also involved in such activities, their numbers are dwarfed by women fulfilling roles as carers, volunteers and educators, whether in the domestic sphere or the informal and formal sectors of the public sphere. Women’s community care activities are generally tolerated even applauded, unless the time supporting others is perceived to encroach on the care and sustenance of their immediate families. However, women’s success in mounting campaigns of protection can immediately encounter the same intransigent beliefs and practices which contribute to their vulnerability to HIV. Women’s accumulated experience in networking, combined with their first hand knowledge of how gender relations make them susceptible to risk of infection, put them in a position not just to ‘speak the truth’ but to organize around campaigns of protection. Yet doing so generates resistance, given those same gender relations which place them in a disadvantaged position both within the context of intimate relations and within the wider society (Kadura, Godfrey, Enoch Mwesigwe and Alice Nambi. 1990). The idea of gender as a relational concept is not usually understood by AIDS practitioners. For policy review and planning, ‘sex’ is employed as a variable, with acknowledgement of categorical differences between men and women (in rates of prevalence or use of condoms). However, these differences are less often understood as a function of the way men and women relate to each other. The new conceptual language of ‘gender’ has been widely interpreted to mean special programs for women. Where men appear they do so in deviant sexual guise—as promiscuous truckers, soldiers, sugar daddies—in much in the same way that sex workers predominate in accounts of women and AIDS. The generality of ordinary men do not appear, and there is little acknowledgement that it is in ‘normal’ social relations between the sexes that danger lies. It is not gendered difference but gendered inequality that puts both women and men at risk. Understanding the ways in which sexuality is constructed and gender relations configured is crucial for strategies of protection against HIV. The subordination of women’s needs and desires in relations of intimacy came through in all of our case studies, expressed in a variety of ways. Understandings of sexuality and the content of sexual practice are embedded in specific cultural histories and are the products of particular experiences of social and economic change. As they evolve, such understandings apply differently to those in different social locations defined by age and marital status, as well as gender (and other social variables). They form the backdrop through which AIDS is experienced and its ramifications felt. However, the epidemic in its turn has influenced the ongoing construction and reconstruction of sexuality and the beliefs and behaviours which constitute it. Accounts of Kapulanga, Rungwe and Kanyama focused on this broader context, attempting to make sense of the response to AIDS and the way blame has been cast particularly on women and young people. In Kapulanga interpretations of affliction based on taboos associated with women’s physiology were drawn on in attempts to come to terms with AIDS. Analysis of the situation in Rungwe showed how disquiet about women’s greater economic independence has influenced perceptions about AIDS. In that case older people often directed their anger at women traders and the young for abandoning former practices and embodying new materialistic values: ‘the girls are hungry for money and have no desire to follow the old traditions’. In Kanyama and Kapulanga, earlier interpretations of certain illnesses as resulting from sexual transgressions have also been invoked in attempts to explain AIDS and distinguish it (or not) as a new illness (Jordan, 1985). In North America and Europe, dominant reactions to AIDS fed on deep seated anxiety about changing patterns of sexual behaviour and what some considered to be an aberrant form of sexuality. From this perspective, AIDS has represented retribution for moral transgression. In Africa, with heterosexual transmission predominant, it has not been sexual orientation which is at issue, but promiscuity—both real and imagined. While this critique has occasionally depicted men as culpable (for example, sugar daddies or rich men), it has equally, if not more strenuously, condemned female sex workers or women regarded as not ‘respecting themselves’. But masculinity—and the behaviour associated with it—has seldom been a concern within public discourse, even though its specific importance was identified early on by a number of commentators. Advocacy of partner reduction has been qualified by an assumption that men’s multiple partnering cannot be expected to be eliminated altogether and needs to be coupled with much stronger advice to use condoms. And here the implicit message has been that condoms are appropriate for casual encounters, but not for marriage. Aids in Africa & Policies It is difficult to overrate the devastation of the AIDS deadly disease in sub-Saharan Africa. In that region, 9 percent of all adults are HIV-infected. Africa will soon reach premature death rates not seen since the end of the nineteenth century. In eleven countries, a baby born in 2010 will live, on average, hardly beyond his or her thirtieth birthday (Stanecki, 2002).. The rate of HIV infection among women attending antenatal clinics in sub-Saharan Africa ranges from 10 to 50 percent, with an average rate in some countries of around 30 percent (UNAIDS, 1998). Women spread infection to their infants in this region at a rate of 21 to 43 percent. The calamity is that AIDS in Africa is mostly avoidable, with models of success found in Uganda and Senegal, where HIV incidence among pregnant women and infants has considerably declined. In North America and Europe, mother-to-infant transmission has been radically reduced using a routine of antiretroviral medication administered to pregnant women and newborns (Lindegren, 1999). The estimated cost of the regimen ($200 with discounts in pricing) makes the treatment unavailable to most people in sub-Saharan Africa where the annual health expenditure per person is between $2 and $40 (Marseille, Kahn, & Mmiro, 1999). Additional barriers comprise the difficulty of obeying with a regimen that involves administering a drug four to five times daily for weeks, the limited infrastructure for dealing out drugs and monitoring compliance, and insufficient maternal-child health care services. Research in sub-Saharan Africa and Southeast Asia has revealed that less expensive short-course antiretroviral regimens diminish perinatal transmission by one-third to one-half. A trial in Uganda of a single oral dose of nevirapine given to the mother and newborn had similar benefits. These results held in spite of of whether women breastfed the child, even though the formula-fed groups had greater reductions in transmission. Economic analyses propose that short-course therapies can achieve significant health and financial benefits compared with the cost of the therapy. As a result, WHO and UNAIDS recommend short-course perinatal antiretroviral therapy and advise HIV-infected women not to breastfeed their infants, where this can be achieved safely (HIV and Infant Feeding: Guidelines for Decision-Makers, WHO/FRH/NUT/CHD/ 98.1) Regardless of the clinical research, economic analysis, and public health guidance, few developing countries have national policies for putting together antiretroviral therapy into antenatal clinics. Those resisting this kind of interventions object on grounds of economics and ethics, but neither argument are persuasive. Thabo Mbeki, president of South Africa, has seen the HIV/AIDS pandemic as part of institutionalized racism and has resisted guaranteeing all pregnant women antiretroviral treatment; he made nevirapine available merely at a number of limited pilot sites (Volmink, Matchaba,& . Zwarenstein, 2001). In response to his intransigence, the Treatment Action Campaign (TAC) sued, claiming a human right to health for pregnant women and infants (Treatment Action Campaign v. Minister of Health, 2002). Under the South African Bill of Rights, "Everyone has the right to have access to health care services, including reproductive health care" ([section] 27(1)(a)). The state must "take rational legislative and other measures, within its obtainable resources, to attain the progressive realisation of each of these rights." in addition; "every child has the right to essential nutrition, shelter, essential health care serves as well as social services" ([section] 28(1)(c)). The Constitutional Court of South Africa has made clear that the state must afford citizens access to these socio-economic rights, though there is no self-standing, enforceable right to a minimum core level of services (Soobramoney v. Minister of Health, KwaZulu-Natal 1998). In its suit, the TAC challenged the government policy of restraining the use of nevirapine merely to specific research and training sites. The Constitutional Court rejected all four reasons extended by the government for stopping the vast majority of pregnant women from gaining access to treatment: incompetence, drug resistance, safety, as well as capacity. First, the Court found that nevirapine will save countless infants from contracting HIV infection perinatally, even if it is managed devoid of full support services. For instance, even though there are cultural taboos and health hazards entailed in bottle feeding (in particular where women do not have access to clean water), nevirapine will decrease perinatal transmission. Second, even though resistant strains of HIV might exist after a single dose of nevirapine, this mutation is expected to be transient. More prominently, the likelihood of drug resistance is small in comparison with the benefits. Third, although there are unpleasant effects with the long-term administration of antiretrovirals, there is no evidence of harm to mother and infant by providing a single table of nevirapine to the mother and a few drops to her baby at the time of birth. Finally, even though government lacks the infrastructure and resources to provide comprehensive HIV prevention services to women and infants (for instance, testing, counseling, long-term treatment, and infant formula), it has ample capability to offer single-dose therapy. The Court made clear that its principal concerns were for indigent women who could not afford treatment and newborns who were permitted to special protection: Protecting the child against the transmission of HIV is ... essential. Their needs are "most urgent" and their incapability to have access to nevirapine deeply affects their ability to enjoy all the rights to which they are entitled. Their rights are "most in peril" as a result of the policy that ... excludes them from having access to nevirapine. (TAC v. Minister of Health, at para. 72). The Constitutional Court consequently held that the "rigid as well as inflexible" policy denying mothers and their newborn children treatment violates the state's constitutional duty to take reasonable measures, within its available resources, to achieve the progressive realization of the right to have access to health care services. "A potentially lifesaving drug was on offer and ... could have been administered within the available resources of the state without any known harm to mother or child." (TAC v. Minister of Health, at para. 74.) Further, the policy of waiting for a protracted period before taking a decision on the use of nevirapine beyond the research and training sites is also constitutionally unreasonable. "We know," said the Court, "that throughout the country health services are overextended. HIV/AIDS is but one of many illnesses that require attention. It is, however, the greatest threat to public health in our country. `During the last two decades, the HIV pandemic has entered our consciousness as an incomprehensible calamity. HIV/AIDS has claimed millions of lives, inflicting pain and grief, causing fear and uncertainty, and threatening the economy (TAC v. Minister of Health, at para. 74).'" TAC v. Minister of Health is a bold judicial decision in a country with a history of racial apartheid, a new constitution, and devastating, conditions of poverty. The Court rejected the claim that it lacks the power to compel the state to act. Rather, citing Brown v. Board of Education, the Court ruled that the "government is constitutionally bound to give effect to such orders [regarding socio-economic rights] whether or not they affect its policy and has to find the resources to do so” (AC v. Minister of Health, at para. 80). Consequently, the Court ordered the government to develop a program for prevention of perinatal HIV transmission, including counseling and testing pregnant women, counseling HIV-infected pregnant women, and making appropriate treatment available. In particular, the Court ordered the government without delay to remove restrictions on access to nevirapine and facilitate its use throughout the country. It is difficult to believe that only a few .years ago the bioethics community in North America focused on the ethics of clinical trials of short-course HIV treatment, rather than the unconscionable burden of disease among African women and children. (Lurie, & Wolf, 1997) Marcia Angell harshly compared the short-course trials to the infamous Tuskegee study because of the placebo-controlled design (Angell, 1997). Yet in the short-course studies, the subjects gave informed consent and were not exposed to risk; the studies were designed to benefit host countries, which desired the research and ethically approved the protocols; and the results had the potential vastly to improve the lives of the world's poorest and disadvantaged mothers and children. The short-course studies included the Ugandan trial, which found a dramatic benefit from a single oral dose of nevirapine. And now the Constitutional Court of South Africa rules that women and infants have a human right to that drug. The decision will save the lives of countless children and, no doubt, influence governments and courts in the African continent and beyond. Conclusion The grip which AIDS has in Africa is in addition a consequence of the pace of social change, as registered in high rates of mobility in search of economic security, later marriage in consequence of more widespread education, a loosening of former mechanisms of sex education. In Africa, heterosexual sex and its corollary of perinatal transmission is viewed as the major source of HIV transmission. Due to the significance of heterosexual transmission of HIV in Third World countries, medical and public health researchers have focused on prototypes of sexual contact. Anthropological research and methods have been called upon to offer information concerning changing sexual behavior as well as expectations among different populations in Africa. While information relating to these issues may be essential for some epidemiological research, anthropologists and other social scientists have been wary of examining data regarding sexual behavior separately from the broader social context in which it was gathered. Research has consistently established that sexual behavior is conditioned and changed by changing social organization, economic expectations and historical events, even by HIV itself. While sexuality is a significant factor in any analysis of HIV transmission, patterns of transmission can only be explained within the broader societal context. Reference: African Rights. 1994. Rwanda: Death, Despair and Defiance. London: African Rights. Aggleston, Peter, Kevin O'Reilly, Gary Slutkin, Peter Davies. 1994. "Risking Everything? Risk Behavior Change and AIDS." Science. 265, 341-345. E. Marseille, J.G. Kahn, and F. Mmiro, "Cost Effectiveness of Single-Dose Nevirapine Regiment for Mothers and Babies to Decrease Vertical HIV-1 Transmission in Sub-Saharan Africa," Lancet 354 (1999): 803-809. HIV and Infant Feeding: Guidelines for Decision-Makers, WHO/FRH/NUT/CHD/ 98.1. Ibid., at para. 86. J. Volmink, P. Matchaba, and M. Zwarenstein, Reducing Mother-to-Child Transmission of HIV Infection in South Africa (New York: Milbank Memorial Fund, 2001). Jordan, Theresa J. et al. 1985. "Long-Term Effects of Early Enrichment: A 20 Year perspective on Persistence and Change. Special Issue: Children's Environments." American Journal of Community Psychology. 13( 4): 393-415. K.A. Stanecki, The AIDS Pandemic in the 21st Century (Washington, D.C.: United States Census Bureau, 2002). Kadura, Godfrey, Enoch Mwesigwe and Alice Nambi. 1990. A Preliminary Report on a Needs Assesment Study of Raki and Masaka Districts with Particular References to the Socio-Economic Impact of the AIDS Epidemic. NS. Kaijage, F. J. 1993. "AIDS Control and the Burden of History in Northwestern Tanzania." Population and Environment 14( 3):279-300. L.A. Guay et al, "Intrapartum and Neonatal Single-Dose Nevirapine Compared with Zidovudine for Prevention of Mother-to-Child Transmission of HIV-1 in Kampala, Uganda," Lancet 354 (1999): 795-802. M. Angell, "The Ethics of Clinical Research in the Third World," NEJM 337 (1997): 847-49. M.L. Lindegren et al., "Trends in Perinatal Transmission in HIV/AIDS in the United States," JAMA 282 (1999): 531-38. N. Soderlund et al., "Prevention of Vertical Transmission of HIV: Analysis of Cost Effectiveness of Options Available in South Africa," British Medical Journal 318 (1999): 1650-56. P. Lurie, and S.M. Wolf, "Unethical Trials of Interventions to Reduce Perinatal Transmission of Human Immunodeficiency Virus in Developing Countries," NEJM 337 (1997): 853-56. Soobramoney v. Minister of Health, KwaZulu-Natal 1998 (1) SA 765 (CC), para. 11 (holding that the state was not in breach of the right to health in failing to provide renal dialysis to chronically ill patients); Government of the Republic of South Africa and Others v. Grrotboom and Others 2001 (1) SA 46, paras. 24 and 38 (holding that the state failed to make reasonable housing provision within available resources for people within the Cape Metropolitan area). TAC v. Minister of Health, at para. 72. TAC v. Minister of Health, at para. 74. TAC v. Minister of Health, at para. 80 (quoting HIV/AIDS and STD Strategic Plan for South Africa 2000-2005). Treatment Action Campaign v. Minister of Health (2002) (4) BCLR 356. Available at http://www.concourt.gov.za/date2002.html. UNAIDS and World Health Organization, WHO Report on Global HIV/AIDS Epidemic (Geneva: UNAIDS and World Health Organization, 1998). Read More