HIV and AIDS: The Global Inter-Connection

OUR FUTURE IS AT STAKE

By Robert E. S. Mugemana

When I began writing this article, I decided to return to a brothel I had patronized during my last year of secondary school, fully expecting that with the advent of HIV it would be closed. I was in for a shock, because not only was it fully operational, but business was booming. The older women were gone, replaced by girls as young as fourteen and no older than twenty-five. One had to push his way through a crowd of men in the corridor. Most of the customers were young men in their twenties and early thirties; there were schoolboys, university students, civil servants, and more, from all walks of life.

One of the girls and I went to the bar to talk. After exchanging a few pleasantries, I asked if she had any condoms. She replied that she did but that I would have to pay extra for them. If I did not wish to pay for the condom, we could have sex without using one. I asked her if she did not fear contracting HIV. "Well...," she said, then thought for a minute and replied uncomfortably, "You cannot do this kind of business if you fear that disease."

As we continued our conversation I inquired about the number of clients she had sex with on an average day. She told me that "the week before and after the end of the month, when business is good, I can have fifteen in one night." When I asked if any of them used condoms, she said: "Two or three, and usually they are married. They fear contracting gonorrhea from us and passing it on to their wives."

I spoke with four more of her colleagues, who all seemed to think it was the responsibility of the man to protect himself. They did not protect themselves from their clients because they all shared a sense of fatalism about becoming infected. As one of them said, "Even if HIV was not there, I would die anyway." A similar attitude is also evident among many young people who, when they discover that former lovers have died from HIV-related diseases, fear that they could be infected but prefer not to be tested and know for sure. Instead they keep their fears to themselves.

There are many brothels in Nairobi which are providing much-needed income for many women. Girls who have dropped out of school due to pregnancy or because they lack the resources to continue their education often turn to sex work as a means of survival. And for men who leave their wives behind in the rural areas while they pursue employment in the cities, brothels offer an inexpensive source of sexual activity.

In fact, this activity now provides a link to one of the major modes of HIV transmission. At the end of each month, men return to their homes in the villages with money that they have earned in the urban areas. Unknowingly, they may be infected with HIV, and thus many infect their wives.

Visiting brothels or having girlfriends while married is fairly common for Kenyan men. With the advent of HIV their behaviour places them, their families, the other women they come in contact with, and the entire society at risk. When a forty-nine-year-old friend of mine recently died of HIV-related illnesses, he left behind two wives, one in the village with six children, and the other in Nairobi with four children. All ten children were in school. He was also responsible for his two elderly parents and occasionally contributed with school fees for a few of his in-laws' children. The entire extended family depended on him. He died without informing either of his wives that he had contracted HIV, and now his wife in Nairobi has developed herpes zoster and oral thrush.

My late friend held a senior position in a large company, and during his burial the managing director was visibly shaken by his untimely death. In the same company, out of a total work force of 185 people, at least fourteen others have contracted HIV, including three senior and five middle managers. Each of these employees, regardless of rank, is an important asset to the company. These fourteen decided to be tested after experiencing symptoms of HIV-related illnesses, but who knows how many other employees, knowingly or unknowingly, are living with HIV.

Now that my friend is gone, who will provide for his children's expenses. He left enough money to cover the following two years' school fees, but once those resources are exhausted, who will step in and provide for the extended family? Where will his wife in Nairobi find money for treatment now that she is ill? How long will it take the company to replace him? How much future productivity has the company lost in terms of the substantial investment they made in him? Should the company begin training new personnel to take over the jobs of HIV-positive employees who can no longer carry out their duties satisfactorily? Should all prospective employees be tested for HIV prior to hiring? And what of the other families and companies in similar and far worse situations? This is not an isolated case. In my career as a counselor I have worked with hundreds of clients, and it frightens me to see how HIV is stealing the most productive men and women in our society.

I have seen doctors, lawyers, engineers, farmers, pilots, educators, legislators, clergymen, and people from all walks of life succumb. They are leaving behind a large gap that will surely be impossible to fill in the near future. Undoubtedly this will adversely affect development. The magnitude of the situation is yet to be felt, but as more people contract HIV we will certainly experience a critical shortage of skilled manpower.

It is also important to remember that agriculture forms the backbone of Kenya's economy. The age group most affected, eighteen to forty-five years old, is the same group that farms the land and feeds the nation. If the present rate of infection is not halted, Kenya, which has almost been agriculturally self-sufficient, will soon have to import food.

Will Kenya survive the onslaught of HIV? Five years ago, I would have thought that question preposterous and dismissed it. But now, although virtually every Kenyan has heard of HIV, how one becomes infected, and what to do to prevent transmission, their awareness barely skims the surface of the problem. However, this awareness has had little impact on the spread of HIV thus far. What worries me most is that more than 90 per cent of those infected with the virus do not know they are infected.

Our nation has the capacity and the infrastructure to contain this epidemic. However, the breakdown of our social structure has reached almost irreversible proportions. This has been exacerbated by authoritarianism, the greatest threat to social justice and empowerment. People must have complete freedom to make positive and informed decisions about their lives. This is the only way that they will be able to take preventive action against HIV. Unfortunately this is not the case for Kenyans at this point in time.

But all may not be lost if the government puts HIV at the top of its agenda. Key ministries must take the lead by setting aside at least 10 per cent of their budgets for HIV prevention programmes in their areas of operation. For example, the ministry of education should ensure that teachers and students, from elementary to the university level, are reached throughout the country. Meanwhile, international aid donors should move to strengthen their commitments, financial and otherwise, to local non-governmental organizations involved in HIV prevention. Not only do these organizations seem to be doing more than the government itself, but they are also more accountable and efficient.

We should stop emphasizing the word AIDS, and instead focus on the term HIV. When we tell people that anyone could be carrying HIV, we must provide them with counselling and information to counteract their belief that only those who are thin and emaciated can transmit the virus. It is the person with HIV who is healthy, sexually active, and unaware that they are transmitting the virus to others, as well as those who are uninfected whom we should be concerned about.

To reach them we must utilize prevention programmes that are specific to Africa rather than instituting programmes that are created for Western countries, but are inapplicable in Africa. The present programme in Kenya is disease-centered and it should be refocused to become person-centered. The disease must be visualized to be understood fully. We must give HIV a human face in order to assist people in overcoming their fears. And we must ensure that each person who tests positive for HIV is provided with counselling services as a right, not as an obligation.

We have to admit and address a number of other HIV-enabling conditions, issues, and practices that prove fertile ground for the virus in our society. We cannot ignore the fact that older men are becoming sexually active with young girls as a means of preventing contraction of HIV, thus placing another generation at risk.

We need to address traditional cultural practices such as the circumcision of groups of boys and girls with one unsterilized blade. We must also examine the risks involved in ritual cleansing where the closest male kin of a deceased husband has sex with the widow, and where one razor blade is used to make ritual incisions on the bodies of remaining family members.

We must also confront and find ways to overcome people's reluctance to use condoms, along with their fatalism and refusal to accept the epidemic as a reality.

Needless to say, Kenyan society must change it's views regarding the status of women. A woman, particularly in rural areas where the majority of our population lives, has no rights or direct income from her labour. She is like a slave and this condition offers her little protection from HIV. As long as women remain in passive and subservient positions, they cannot question their husbands' sexual practices. Even when a wife is aware of her husband's involvement with another woman, she suffers in silence. Countless women who have never had sexual relations with men other than their husbands, have become infected as a result of his behaviour.

When a husband becomes ill, it is the woman who nurses him. When a child is ill, it is the woman who nurses it. But when a woman is ill, she nurses herself. When a couple are both HIV-positive often the husband dies before the wife. Thus the wife is left to struggle with their children alone, to endure and face stigmatization and isolation, and ultimately to face her own death alone. These women desperately need support and counselling. Something also must be done to counter the prevailing belief that any incurable disease is a curse and the person affected should be left alone to die.

The majority of Kenyans are Christians. Our churches are extremely powerful and they are much more vocal than government regarding the social issues of concern today. Yet this enormous power has not been utilized to educate their worshippers about the risks and dangers of HIV infection. We need the churches to use their privileged position and influence to prevail upon congregations to advocate prevention, put it into practice, and positively respond to those who are ill.

Kenyan society is fragmented due to a policy of divide and rule practiced by the colonialists for decades. Yet despite that fragmentation, families still retain a strong sense of identity and togetherness. In Kenya one does not live as an individual, but rather as part of a family. In times of need one turns to their family for support and care. African families traditionally care for their loved ones at home, especially the terminally ill. We must strengthen the family's capacity for caregiving as we begin to depend on them for care of those living with HIV. In two years our hospitals and healthcare institutions already stretched to their limits will be unable to accommodate the increasing number of patients with HIV-related illnesses. Home-based care is the only feasible solution. To cope with HIV, basic nursing skills should be incorporated into adult literacy classes which are being conducted at the community level throughout the country.

Despite all the difficulties and pain this epidemic causes, there are some positive aspects to HIV. As people and communities recover from the initial shock of HIV and its effects, they have begun to band together and seek methods to care for those of us living with HIV and AIDS. Also, single, young men and women are getting married with the intention of committing to monogamous unions as a means to avoid contracting HIV. Slowly, global connections are being made to meet the challenge of this epidemic. Perhaps most importantly, the epidemic has shown us that the world is indeed one family, equally vulnerable, and that human love knows no boundaries of nationality.

Biographical note

Robert Mugemana instituted the HIV programme of the Norwegian Church Aid Society in Nairobi, Kenya and later did some consulting for UNDP,HIV and Development Programme. He was a freelance journalist who received his training at the University College of Eastern Africa in Kenya and the Africa Literature Centre in Zambia. Robert married in 1991. He died of AIDS in 1993.