HIV in sub-Saharan Africa

AIDS-related illness is a leading cause of death in sub-Saharan Africa, where more than 22.5 million people live with HIV. Two million Africans are infected with HIV every year, primarily through sexual transmission. Millions of children have lost – and will lose – their parents to AIDS-related illnesses. There are 1.8 million children under the age of 15 already living with HIV.

The virus continues to spread invisibly and rise where strategies to increase awareness and understanding of prevention are not sustained.

Responses to HIV

Since 1997, the response to the HIV pandemic has emphasised and funded the supply of HIV-slowing medications, anti-retrovirals (ARVs), which have been of great significance for millions of people, enabling them to live healthily without progressing to AIDS, despite having contracted HIV.

However, the ARV strategy can have complications – from the challenge of maintaining a constant supply, to the spread of mutated strains of HIV, the problems of people’s access and nutrition, and the side-effects that people on ARVs can experience.

Meanwhile, support for preventing the spread of the virus among sexually active people of all ages has been relatively inadequate and hesitant.

Recent years have seen the preaching and funding of ‘abstinence/fidelity’ messages and strategies, interwoven with rejection and stigmatisation of condom use. Yet the scale of the pandemic shows that many people of every faith background, social status and age group do (for a range of reasons) engage in sexual relations before and outside of marriage. Marriage remains a high-risk situation for women for contracting HIV – and the sexual realities behind this need to be faced more honestly and strategically.

Research about attitudes and behaviour continues to show that many sexual interactions occur without condoms, or with inconsistent and incorrect condom use.

Working with men and boys

Gender-focused approaches have overwhelmingly emphasised empowering women to protect their reproductive health. However, if boys and men are sexually active and neglect the protection of their bodies, they unwittingly affect and infect their families and partners. Comprehensive HIV prevention includes supporting men and boys, getting them to think and talk about condoms and condom use.

Cultural norms and expectations around masculinity create obstacles to understanding the significance of sexual safety. Boys are pressured to avoid seeming weak; as a result they often develop a bravado of ‘knowing’ to mask uncertainty and ignorance.

These pressures exacerbate risky sexual behaviour and inhibit condom use. Older men often hint that sexual knowledge is ‘instinctive’ for men – not a talking matter – so young men enter into sexual relations burdened by ignorance, myths, misplaced confidence and short-sightedness that can damage their own and their partners’ bodies.

Opening discussions among men from diverse backgrounds can support the understanding of condom use as a key protective tool on the side of men’s well-being.

HIV and AIDS in plain language: why condoms matter    

The importance of avoiding HIV infection and re-infection and the importance of using condoms only make sense if you clearly understand what HIV is and what AIDS is – and can clearly visualise how HIV can enter your body, what it does and how it can be passed on.

AIDS stands for: Acquired Immune-Deficiency Syndrome.   

HIV stands for: Human Immunodeficiency Virus.

AIDS is a condition of life-threatening vulnerability that develops years after your body has been infected by a virus called HIV.

Once HIV gets into your body, there is no way of getting rid of it, and it keeps multiplying slowly and invisibly inside you.

HIV targets your immune system – the natural, invisible, defence system that usually wards off all kinds of infections. The immune system is important for keeping you well, healing you and ridding your body of illnesses.

‘Immune deficiency’ is the breakdown of the body’s defence system, leaving you exposed to infections and illnesses that can threaten your life.

If you get tested and find out you have the virus, you may have access to ARV medications. Continuous use of ARVs can inhibit the spread of HIV and keep you well and active.

Without these ARVs, the build up of HIV eventually disables your body’s natural defence system. In this state, called AIDS, you become fatally vulnerable to a range of (often familiar) illnesses.

Doctors and scientists realised HIV existed only about 30 years ago. It has spread in every country in the world – but in some places it spreads much faster than in others.

Millions of people have died prematurely as a result of AIDS-related illnesses; many millions are living with HIV and millions more are still contracting the virus. 

HIV is transmitted only in certain, known ways.

HIV moves from the body of an infected person to that of another person through contact of certain liquids in the body in only the following ways:

• Through HIV-infected sexual fluids making contact with another person’s sexual fluids or blood.
• Through HIV-infected blood making contact with another person’s sexual fluids or blood.
• From an HIV-positive mother to her baby during pregnancy, childbirth or through breast milk.

Ways of transmission                

Here is a clear account of the main ways HIV is spread:

1. Unprotected sexual contact – penetrative sex without a condom, where sexual liquids mix and pass from one body to another.

• A man can contract HIV from an HIV-infected female partner when his penis comes into contact with the ordinary, everyday sexual moisture inside her vagina (or the moist, outer lips of the vagina).
• A woman can contract HIV from an HIV-infected man if his semen makes contact with her genital area – inside the vagina or the outer lips of the vagina (the clear droplets that come before his full ejaculation would also contain HIV).
• Anal sex is a high-risk activity, because of the risk of bleeding: men and women can contract HIV during unprotected anal sex with an HIV-infected partner (both men are at risk of infection in either position).
• Oral sex can be a risk if there is any bleeding or vulnerability in the mouth or an infection in the throat.
• Sexual contact involving any bleeding – where blood and sexual fluids (of the man or of the woman) come into contact – is particularly high risk. Sores from other sexually transmitted illnesses (STIs) may bleed during sex. Unprotected genital sexual contact involving violence has a very high risk of infection for both men and women.
• Intoxication and carelessness – non-injecting drug use does not involve blood-to-blood contact, but it often leads to unsafe, unprotected sexual interactions. Alcohol poses the same risk.

2. Blood-to-blood contact – where the blood of an infected person makes contact with the blood of someone else.

• This can happen through sharing needles used to inject drugs, when tiny droplets of blood (with HIV) are transferred to the next person using the needle.
• Repeated use of unsterilised needles for medical reasons, or transfusions of untested blood (e.g. brought from family or purchased at the very last minute) can also transmit HIV.

3. Breast milk of an HIV-infected mother to unborn child

• The baby may not have HIV in his/her blood at birth, even if his/her mother has HIV, but the infant can contract it from bleeding during birth or through breast-feeding. If a mother tests and finds she has HIV, there is a special ARV that she can take before the birth, more of which is given to the newborn baby. In such cases, the baby has a very high chance of not developing HIV. Advice on breast-feeding should be sought from local clinics.

Care is required during any or all of the above activities – whatever your age or faith, life situation or marital status, or however in love or nervous, angry or confident you are.

Most people who have HIV are unaware of it. They may live with the virus for years without experiencing any of the symptoms that indicate they should get tested – and they may have many reasons to keep any risk behaviour secret from their partners.

Realistic prevention                

Condoms, if used correctly and regularly, offer high protection from HIV and most other STIs.

Other strategies that help reduce HIV transmission:

• Circumcision can help reduce men’s chances of contracting HIV (this does not protect their partners).
• People living with HIV who take ARVs have a lower risk of infecting others with HIV.
• However, condoms need to be used – even where a man has been circumcised and even when infected sexual partners are taking ARVs.

Microbiside gels will hopefully soon be available for women to use to lower the risk of getting HIV from men who refuse to wear condoms. The ARV gel would be inserted into the vagina to form a barrier to the HIV in a man’s semen.

The best way to stay safe is to have a clear understanding of how the virus is passed from one person to another, to maximise strategies to avoid transmission and to know how to use a condom correctly and to discuss condom use and sexual safety with every sexual partner.

Understanding safety from HIV

HIV is concentrated only in sexual fluids, blood and breast milk – not in other body fluids, and not in saliva or sweat, or tears or urine.

This means there is no risk of ‘catching’ HIV by living with someone, touching them in ordinary ways, sharing a classroom or office, working together, swimming together, eating off the same plate, sharing clothing, sharing books or cups. There is no risk from any of these forms of contact.

You cannot ‘catch’ HIV from sneezing or coughing.

Animals and insects do not transmit HIV. Mosquitoes do not spread HIV.

There is no reason to fear daily, ordinary contact with people who have HIV or AIDS.

This understanding is really important – it allows one to be at ease around people living with HIV instead of being afraid; it allows one to care for people with AIDS confidently. This understanding is also important to stop discrimination that is based on the myths and misinformation that still circulate in many places.

How HIV works inside the body              

Once HIV enters the body, it enters the body’s DNA and reproduces itself in all new blood cells.

It can take several years (the time varies from person to person) before an infected person has any symptoms suggesting infection. During this period, the infected person risks infecting others.

Here are some ways the body commonly responds to HIV – if it progresses without being identified by testing and without ARV treatment:

• Around the time of infection there may be brief, flu-like symptoms (these are not always noticeable).
• Then, there may be no symptoms for several years.
• Then, mild, occasional symptoms occur (these vary from person to person) – e.g. tiredness, fevers, recurring night sweats, prolonged swelling of glands, diarrhoea, weight loss.
• Then, specific illnesses appear and recur, such as pneumonia, malaria, tuberculosis and yeast infections. In different places,there are different lists of ailments that most commonly take advantage of a depleted immune system.
• HIV may finally be identified through testing (probably on a doctor’s recommendation).
• Only when the person suffers from a range of illnesses that come one after the other – or overlap – because the immune system is so weakened, does it become AIDS.

An AIDS diagnosis is only given when the body has crossed a threshold of resilience and the body finds it increasingly hard to fight off ‘opportunistic’ infections.

AIDS causes the body to gradually give in to illnesses that healthy bodies usually recover from. Death eventually comes from illnesses the body cannot resist or ward off.

The time from infection with HIV until AIDS develops can take several years.

There are no fixed symptoms of AIDS, as it is not an illness in itself. It is a condition of vulnerability that lets other illnesses take hold of the body.

Under the AIDS ‘umbrella’, the ‘opportunistic’ illnesses that can develop (some may become life threatening) can include:

• Rashes   
• Pneumonia (lung infections) 
• Chronic diarrhoea, weight loss    
• Herpes, genital sores 
• Tuberculosis 
• Malaria
• Thrush – fungal infections of mouth, throat and vagina   
• Viral infection causing blindness or mental illness, or affecting the nervous system
• Forms of cancer, especially skin cancer
• Bad reactions to common illnesses such as colds and flu    

HIV medications: anti-retrovirals (ARVs)

ARVs are not a cure and cannot rid the  body of HIV, but they can radically slow the spread of the virus in the body and keep the immune system resilient for many years. However, they need to be taken regularly for the rest of the infected person’s life.

ARVs reduce but do not eliminate the risk of passing HIV on through unprotected sex. Irregular use of ARVs can produce resistance to the medication. If you start taking ARVs, then stop, the virus surges back and makes you more ill. Meanwhile, your body may have become resistant to those ARVs, so they will no longer work for you and others may not be available. So taking them regularly is extremely important.

Taking other traditional medicines while on ARVs may reduce the effectiveness of ARVs or cause unexpected side-effects.

ARVs cause HIV to mutate, as it tries to fight the medication and get around it. This risks putting medication-resistant HIV back into circulation via unprotected sex.

The toxicity of ARVs, which need to be extremely strong to contain HIV, can have challenging physical side-effects.

Only condom use can enable people living with HIV to have safe sexual intercourse, prevent them being at risk of re-infection and help them protect their partners.