HIV, Poverty, and Sex in Sub-Saharan Africa: Why the Condom Does Not Protect Women from the AIDS Virus

8/14/2019 HIV, Poverty, and Sex in Sub-Saharan Africa: Why the Condom Does Not Protect Women from the AIDS Virus

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HIV, SEX AND POVERTY IN SUB-SAHARAN AFRICA: WHY THECONDOM DOESNT PROTECT WOMEN FROM THE AIDS VIRUS

Lisa Nicol Woods

Dissertation Supervisor

Dr. Edward Simpson

Medical Anthropology

This dissertation is submitted in partial fulfilment of the requirements for thedegree of MA Medical Anthropology of the School of Oriental and African Studies(University of London)

15 September 2009

10,000 words

DeclarationI have read and understood regulation 17.9 (Regulations for Students of SOAS)concerning plagiarism. I undertake that all material presented for examination ismy own work and has not been written for me, in whole or in part, by any other

person(s). I also undertake that any quotation or paraphrase from the publishedor unpublished work of another person has been duly acknowledged in the workwhich I present for examination. I give permission for a copy of my dissertationto be held at the Schools discretion, following final examination, to be madeavailable for reference.

Name : Lisa Nicol Woods

Signature:


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TABLE OF CONTENTS

INTRODUCTION 4

CHAPTER 1 THE DISHARMONIOUS DISCOURSES ON AIDS IN AFRICA 8

ANTHROPOLOGICAL CONTRIBUTIONS TO AIDS RESEARCH IN AFRICA 8 ANTHROPOLOGISTS AS HANDMAIDENS 8 ANTHROPOLOGISTS AS CULTURAL EXPERTS: THE COMMUNITY PARADIGM 9 ANTHROPOLOGISTS AS POLITICALECONOMISTS : THE STRUCTURAL VIOLENCE PARADIGM 10 THE FUTURE : AN ANTHROPOLOGICAL SYNTHESIS 10 AIDS, CONDOMS AND THE BIOPOLITICAL 11 FROM GLOBAL TO LOCAL: RELIGIONS INFLUENCE ON CONDOM PROMOTION AND USE 13 A M INIANTHROPOLOGY OF CONDOM PROMOTION IN AFRICA 15

CHAPTER 2 FEMALE BODIES, MALE CONTROL 19

THE PERFORMANCE OF TRUST 20 THE RISKYSEX OF M ARRIED COUPLES 21 THE SYMBOLIC AND M ATERIAL VALUE OF FERTILITY 23

CHAPTER 3 THE SOCIAL AND COSMOLOGICAL DIMENSIONS OF SEX 25

REPRESENTATIONS OF SEMEN 25 CONDOMS AND GOOD SEX DON T M IX 26

CHAPTER 4 THE SOCIAL PRODUCTION OF AIDS 28

THE SEXUAL CONSEQUENCES OF POVERTY 28 M ASCULINITY, M IGRATION , AND SEXUAL RISK TAKING 29

CONCLUSION 31


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INTRODUCTION

The crux of HIV preventiona lies in the epidemiologically sound risk reductionstrategy known as the ABC approach. For the Joint United Nations Programmeon HIV/AIDS (UNAIDS), ABC means: Abstinence or delaying first sex; being saferby being faithful to one partner or by reducing the number of sexual partners;and correct and consistent use of condoms for sexually active young people,couples in which one partner is HIVpositive, sex workers and their clients, andanyone engaging in sexual activity with partners who may have been at risk ofHIV exposure (UNAIDS, 2004:6).3 The condom remains the cornerstone of HIVprevention and is the most controversial component of ABC. Religiousorganizations and traditionalists oppose the condom on grounds that it leads tosexually immoral behavior; but biomedicine hails the condom as the single mosteffective technology to prevent the transmission of HIV.b

The social marketing of condoms remains at the forefront of AIDS prevention inAfrica but the condomc has failed to reduce prevalence rates in general, amongstwomen in particular. In fact, UNAIDS now reports that AIDS an illness onceassociated with male homosexuals and injecting drug users in America has awomans face. Recent statistics show that women comprise nearly 50 percent ofall people infected with HIV worldwide, and 60 percent of people living withHIV/AIDS in SubSaharan African (UNAIDS, 2008:33).4 The feminization of AIDSposes a challenge for the ABC approach to HIV prevention. For women and girlswho are sexually assaulted, in abusive relationships, or see sex as the only meansof survival, abstinence is not a realistic option; monogamy only works if bothpartners play by the same rules; and condom use is almost invariably a maledecision (Wintersgill, 2004:1).

Opponents of diseasespecific health interventions claim that the intense focuson AIDS prevention distorts international health aid, and steals valuableresources needed to boost overall health systems (England cited in Morris,2008).5 I argue that the syndrome has earned the attention it receives in Africabecause the continent bears a disproportionate amount of disease and deathassociated with the syndrome, and it is the leading killer of women. For example,in 2007 an estimated 1.9 million people were infected with HIV in SubSaharanAfrica, bringing the known number of people living with HIV to 22 million. About

67 percent of the 32.9 million people living with HIV reside in this region; and 75percent of all AIDS deaths in 2007 occurred there (UNAIDS, 2008).6 The UnitedNations Childrens Fund reports that an estimated 12 million children from 0 to17years old have become single or double orphansd because of AIDS;subsequently, the region is home to 80 percent of the developing worldschildren who have lost a parent to AIDS (UNICEF, 2006).

a The human immunodeficiency virus is thelentivirus that causes acquired immunodeficiencysyndrome (AIDS),b In this document the AIDS virus and HIV have the same meaning, and HIV/AIDS refers to thediscursive field, research endeavours, and people affected by or living with the illness.c This dissertation will focus on the male condoms because the female condom is not widelyavailable in subSaharan Africa because it is relatively expensive (UNAIDS, 2008).d Single orphans have lost a mother or father; double orphans have lost both parents.


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Figure 1: HIV prevalence (%) amongst adults, 1549 in Africa (2007) (UNAIDS, 2008b: 39)7

These worrying trends persist regardless of an increased supply and demand forcondoms on the continent. I have therefore used social science studies andethnographic accounts from countries in central and eastern Africa (theDemocratic Peoples Republic of Congo, Tanzania, Uganda); southern Africa(Malawi, South Africa, Zambia, Zimbabwe), and Western Africa (Nigeria) all inthe SubSaharan African region. Although impossible to construct a single,unifying cultural perspective from such incongruent ethnicities and countries,salient themes appear: condoms are associated with promiscuity and reducedfertility, women depend on men to use condoms, condoms interrupt the pleasureand meaning of sex, and condom use is a controversial topic amongst regularpartners.

First, let me state that I am by no means anticondom! On the contrary, I believethat every human should have the freedom to make choices in regards to his orher sexuality without interference from the Church or State. While I disagreewith the Vaticans distortion of scientific data to further its theological agenda, I

cannot ignore ethnographic trends, which illustrate that the introduction ofcondoms into stable heterosexual unions represents an unacceptable risk tomany subSaharan African women in particular. I cannot silence anthropologicalstudies, which underscore a wide range of cultural attitudes toward sex andprocreation, which make condom use socially unacceptable. In this paper willexamine the following:

In Chapter 1, I rely on the Foucauldian concept of the discourse as thething thatcreates the effects of truth or decides what is in the true. I apply the notion ofdiscourse in my analysis of the religious, moralist, and biomedical trends, whichdictate HIV/AIDS research and condom promotion in SubSaharan Africa. I tracethe role of anthropological contributions to sex and AIDS research in Africa fromthat of the handmaiden who delivered exotic cultural practices to support the


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biomedical fascination with the epidemiological patterns of HIV/AIDS, to that ofthe cultural expert and political economist who oppose themedicalization ofHIV prevention, and look to sociocultural and economic forces which conspireto socially produce AIDS. This chapter also examines the effects of the Vaticanand local churches in opposing condom use, the raging debate between religionand science on the appropriateness of the condom to reduce the threat ofHIV/AIDS, and ethnographic accounts which manifest the dynamics of thisdebate. I conclude with an ethnohistory of condom marketing in subSaharanAfrica and calls for an improved evidence base for condom promotion, and theexpansion of HIV prevention to include nonbiomedical factors of infection.

Chapter 2 looks at the value of condoms in relation to womens ability tonegotiate condom use with regular sexual partners. I posit that the condom isimpotent to protect vulnerable women from HIV infection because of pervasivegender inequality. My definition of gender inequality is based on access to cash,credit, land, political participation, and the implicit social acceptance that awomans bodily integrity is not as important as her husbands conjugal rights.The symbolic and material value of fertility is also examined in relation towomen and mens acceptance of condoms and the implications this holds forcondom promotion. Finally, I tackle the issue of risk and trust in relation tocondom use in stable unions. I use ethnographic analyses from Tanzania andMalawi to illustrate how condom use amongst married couples can constitute animmediate risk greater than that posed by a dimly understood virus.

In Chapter 3, I examine the fate of the condom in cultural contexts where bodilyfluids have cosmological and social dimensions. I juxtapose western biomedicaldefinitions of procreation and good sex with ethnographic accounts from Zambiaand Tanzania to illustrate how condoms can oppose the cultural meanings of sexand faces opposition as the cornerstone of HIV prevention. In the studiesanthropologists recommend a multifaceted approach to HIV prevention, whileurging condom programmers to use ethnographic data to implement moreculturally appropriate interventions.

In Chapter 4, I adopt the paradigm of the political economist anthropologist andexamine how structural and economic forces such as structural adjustmentprogrammes (SAPs) and persistent poverty lead to an environment thatnecessitates, even expects, women to trade sexual favours for subsistence. I willalso explore the role that urbanrural migration plays in mens risk to HIVinfection, and the construction of masculinities and sexualrisk taking of menworking in the South African gold mines. The overarching theme of this chapteris that the socioeconomic dynamics in which sexual relations occur often escapehealth belief models and biomedical assumptions, which posit that awareness ofHIV infection and access to condoms, will lead to their use. In conclusion, I throw down the gauntlet to medical anthropologists tospearhead efforts to demedicalize HIV prevention, and to revisit the fieldworktradition to ensure that the lebenswelt of people affected by HIV/AIDS are

accurately depicted. Medical anthropologists are also challenged to advocateinternational organizations for the inclusion of the cofactors of HIV


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transmission poverty and gender inequality into HIV prevention efforts, andto collaborate with traditional healers to craft the appropriate local responses tothe AIDS epidemic.


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CHAPTER 1

THE DISHARMONIOUS DISCOURSES ON AIDS IN AFRICA

Anthropological Contributions to AIDS Research in AfricaSince the emergence of the AIDS epidemic in the 1980s there has been adisparate anthropological approach to the understanding of its epidemiologicalpatterns and the sociocultural factors driving the epidemic. Leading medicalanthropologists have critiqued the disciplines past involvement, and are callingfor a return to the basic anthropological principles of doing no harm andensuring that the lebenswelt of people affected by HIV/AIDS are accuratelyportrayed in ethnographic analyses and joint social science research endeavours.

I will rely on the stylised representations of anthropological involvement in AIDSresearch in Africa, which include (Farmer, 1998):8

1. Anthropologists asHandmaidens : The Biomedical Paradigm;2. Anthropologists asCultural Experts : The Community Paradigm;3. Anthropologists asPolitical Economists : The Structural Violence

Paradigm; and4. The Future: An Anthropological Synthesis.

Anthropologists as HandmaidensColonial administrators, missionaries, adventurers and armchair anthropologistsstudied African sexuality as part of a morbid curiosity into the exotic lives ofthe natives (Gausset, 510:2001).9 During this period of fascination with theexoticism of the Other, anthropology suffered a crisis in representation amoment of selfreflexivity that threatened to paralyse the discipline afterdecades of allying with colonial administrations, and other unfortunate misstepssuch as ethnocentrism and ethical issues regarding the AmericanVietnamesewar. The question of whether anthropology was the bastard of colonialism orthe legitimate child of the Enlightenment coincided with the cessation of sexualresearch on the continent. But AIDS made it legitimate to study sexuality inAfrica again, and at the behest of biomedical researchers, anthropologists were

asked to problematise the ratio of male to female cases of AIDS. In Africa, theprevalence ratio stood at 1:1 while in the northe the ratio was 13:1 (Packard andEpstein, 1991). Anthropologists were commissioned to analyse ethnographicrecords and conduct fieldwork to solve the following epidemiological riddles:

1. Why is HIV in Africa transmitted differently from the west?2. Why are as many African women as men infected with HIV?3. Why does African sexuality result in heterosexual infection?

Since biomedical researchers had already constructed a line of inquiry thatexcluded any other possibilities for the varied patterns of HIV transmission,

e In this paper, north refers to North America and Western Europe.


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anthropologists focussed on the differences of the African, the quintessentialother, and relegated other possibilities to the margins. Like the first studies ofAfrican sexuality, it was once again the exotic, traditional, irrational andimmoral practices that were the focus of the research. If the pattern of AIDSepidemics was different in Africa than in Europe, the explanation obviously hadto be the difference between African and European culture and sexualities. Someused the Human Relation Files Area in order to find significant relations, or totry to establish an ethnic cartography of the risk of infection according to thesexual and ritual practices (Fassin cited in Gausset, 2001:511). This ethnopornography revealed scarification rituals performed with the same knife, drysex, widow inheritance, wife sharing, witchcraft beliefs (as opposed to Kochsgerm theory) the rumoured mixing and sharing of monkeys blood in lovemagic (Gausset, 2001). This ethnographic evidence was presented asculturallyspecific HIVrelated risk behaviors. For example, in theSocial Factorsin the Transmission of Control of AIDS in Africa (1987), commissioned by theUnited States Agency for International Development (USAID), an anthropologistreported the following of the Tonga in Zambia:

There is a widespread fear of impotence [in Africa]. Our readingsmention instances where an older man might ask a younger manto impregnate his wife. The Gwembe Tonga of Zambia useeuphemistic invitation in these circumstances go and cut woodfor me, my friend This illuminates our understanding ofperception of sexuality incertain traditional African settings butalso indicates another though limited instance of a possibleroute for spreading AIDS through increasing the number of sexual

partners (Brokensha cited in Packard and Epstein, 1991:775).10

While there is no argument that this sexual practice is a pathway for HIVinfection, this construction of risk fueled the notion that Africans are sexuallypromiscuous, and diverted the focus from more common circumstances in whichHIV is transmitted. In other cases, anthropologistreported sexual practices weredivorced from its attendant social and cultural contexts, and excluded the morecommon but less exotic causes of HIV infection such as malnutrition, poverty, illhealth, and over and underdevelopment (Packard and Esptein, 1991).

Anthropologists as Cultural Experts: The Community Paradigm As HIV prevention efforts failed to have its desired effect, anthropologistsdiverted their focus from individual risk behaviors. [I]t had become clear that afar more complex set of social, structural, and cultural factors mediate thestructure of risk in every population group, and that the dynamics of individualpsychology could not be expected to fully explain changes in sexual conductwithout taking these broader issues into account (Ramin, 2007:128). As such,the early 1990s saw anthropologists as cultural experts, promoting theunderstanding of culture as the key to a more enlightened AIDS preventionstrategy. For example, Lyons (1997) identified disparate attitudes towardcondom use in Uganda which ranged from condoms are not African, condoms

will promote promiscuity and moral lassitude, condoms are a ploy to controlour population size, condoms kill women, and condoms are evil to condoms


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Such an approach opposes the notion that medical anthropologists should simplybear witness g to AIDS suffering and death. Indeed some anthropologists arecalling the failure to abandon the trope ofneutral observer while AIDS decimatesa continent, an unforgivable dereliction of professional and moralresponsibility (Bayer cited in Bolton, 1992:288). Farmer et al have throwndown the gauntlet to their colleagues to produce full ethnography, return to thefieldwork tradition, and to abandon anthropologists everincreasing reliance onsurveys, questionnaires, and focus group discussions (Bolton, 1992:298). In thisregard, Farmer (1992) established a modus operandi for anthropologists in theera of HIV/AIDS:

1. Explain why AIDS is fast becoming an illness of the disadvantaged;2. Use ethnography as a cultural critique;3. Counter false information;4. Document the effects of misinformation and join forces with community

groups in using such information to develop cultural activist responses tothe epidemic; and5. Witness and honour the memory of people who have died from AIDS

(cited in Bolton, 1995:288).12

Although the future of HIV/AIDS research is dynamic, the mainstay features ofthe epidemic increasing prevalence rates regardless of HIV preventionmeasures, scientific failures to discover a viable vaccine or microbicides, and theincreasing disparity of infections between the rich and poor, and that of male andfemale are indications that a synthesised anthropological approach would beuseful in the future. Medical anthropologist in particular must invoke the spiritsof Franz Boas, himself a scientist, who asserted the role of the anthropologist asscientist was to speak truth to power (Rabinow citing Boas in DAndrade1995:402)13 and that of Bronisaw Malinowski, who offered that ethnographyis the way to grasp the native's point of view, his relation to life, to realize hisvision of his world (Malinowski, 1961:25).14 Successful AIDS research in Africa,and elsewhere in the world, will depend on anthropologists resolve to integratethese vantage points into biomedical research agendas.

AIDS, Condoms and the BiopoliticalThe history of medical anthropological contribution to HIV/AIDS researchlargely funded and influenced by western biomedicine should lead us to at leastconsider the controversial statements of Pope Benedict XVI. The pontiff, on theplane to Yaound, Cameroon in March 2009 said: Condoms arent the answer tothe scourge of HIV in Africa. You cant resolve it with the distribution ofcondoms. On the contrary, it increases the problem(cited in the New YorkTimes, 2009).15 Was the pope wrong about the power of the condom to decreaseHIV prevalence rates in Africa or was he wrong to challenge science? Haveinternational health agencies been blinded to the social milieu surroundingcondom use in Africa or does the technological effectiveness of the condomappropriately drown out cultural noise? Have anthropologists from the political

g Farmer (2007) examines the notion of bearing witness as one way that anthropologists can bemorally engaged with the powerless. He states that bearing witness consist of reporting the stoicsuffering of the poor, and joining in pragmatic solidarity with the oppressed.


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economist or cultural expert traditions used ethnography to lend a localperspective on the acceptability of condoms in Africa, or does biomedicine trumpall?

Religion and science remain at loggerheads regarding condom promotion andthere are no signs that either side will acquiesce. Tensions peaked when CardinalAlfonso Lpez Trujillo, the Vatican's Pontifical Council for the Family, said to theBBC the AIDS virus is roughly 450 times smaller than the spermatozoon. Thevirus can easily pass through the 'net' that is formed by the condom(Bradshaw,para. 3:2003).16 Health organizations fired back intact condomsare essentiallyimpermeable to particles the size of sexually transmitted disease pathogens,including the smallest sexually transmitted virus (UNAIDS, 2004:15).17International preoccupation with AIDS in SubSaharan Africa and the insistenceon condoms as a central way to curb mortality is a key premise in MichelFoucaultsbiopolitical . Biopolitics deals with the population, with the populationas political problem, as a problem that is as once scientific and political, as abiological problem, and as powers problem (Foucault, 1976:245).18 Global andlocal powers are introducing mechanisms abstinence, fidelity, and condoms tonormalise sexual behavior; and while Power cannot control death, it can controldeath rates.

This emergent power of regulation consists of making live and letting die(Foucault, 1976:247). To this extent, the remarks of Pope Benedict XVI evoked afirestorm of criticism from heads of state, international health agencies, AIDSactivists, nongovernmental organizations and members of the general public. Inthe New York Times, Rebecca Hodes of the Treatment Action Campaign in SouthAfrica said the pope should focus on HIV prevention through assisting in thecreation of an informed demand for condoms, and by helping to close thecondom gap in the region. Instead, his opposition to condoms conveys thatreligious dogma is more important to him than the lives of Africans (Hodes citedin New York Times, 2009).19 In other words, the pope was accused of lettingdie.

Figure: Tony Auth, Philadelphia Inquirer, 19 March 2009. 20


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In an editorial The Lancet demanded an apology from the pope, and accused himof engaging in reckless behavior that could undermine AIDS prevention efforts inthe region. By saying that condoms exacerbate the problem of HIV/AIDS, thePope has publicly distorted scientific evidence to promote Catholic doctrine onthe issue. Anything less from Pope Benedict would be an immense disservice.(de Leon et al, 2009:461).21 A medical doctor and applied medical anthropologistdefended the popes position in an editorial forThe Washington Pos t. EdwardGreen, then a senior research scientist at the Harvard School of Public Health,offered that condom promotion has worked in places such as Thailand andCambodia because HIV is mostly transmitted through commercial sex. This hasenabled governments to address the epidemic by enacting condom use laws inbrothels. In Africa, however, the pattern of the epidemic is different becausepeople often dont use condoms in stable partnerships because it shows a lack oftrust. It's those ongoing relationships that drive Africa's worst epidemics(Green cited in The Washington Post, 2009).h

Pope Benedicts opposition to condoms comes as no surprise as the CatholicChurch disagrees with artificial contraceptives under all circumstances. Hispredecessor Pope John Paul II also preached that abstinence and fidelity shouldbe the focus of HIV prevent, not condom use (Washington Post, 2005).22 But thecurrent pontiffs assertion that the condom increases the problem represents adirect attack on established scientific facts proven by laboratory studies[which] show that male latex condoms are impermeable to infectious agentscontained in genital secretions (UNAIDS, 2004).23 This has transformed thepontiff from a sacred symbol to one of the profane a person who distortsscientific evidence makes false scientific statements and doesnt care about

the lives of Africans. The basis for this strong counterattack was anticipated inthe Elementary Forms of Religious Life (2008), where Durkheim posits that thevalues of science have become sacred because of its perceived role in thewellbeing of humankind. Durkheim offered that if religion attacks the facets ofscience, people would come to the defence of science, because the attack is anoffence to their moral senses (Durkheim, 2008).24

From Global to Local: Religions Influence on Condom Promotion and UseWhile the Vatican and biomedicine spar over condom use in the internationalarena, local African religious leaders and elder men in several African countriesoppose condom promotion on the grounds that they lead to promiscuity. Thishas been documented in Uganda (Obbo, 1995), Zambia (Bledsoe, 1991),Tanzania (Bujra, 2000; Coast, 2007), Zimbabwe (Bassett and Mhloyi, 1991) andelsewhere in SubSaharan Africa. Obbo (1995) demonstrates the social power ofthe hagiarchy and gerontocracy with a story that severely damaged the AIDSprogramme of the school.

h UNAIDS states: The pattern of concurrent partnerships is different to the pattern of serialmonogamy more common in the west and can result in much higher rates of HIV transmissionacross communities. Viral load and 'infectivity' is much higher during the three to four week'acute infection' window period that initially follows HIV infection. The combined effects of

sexual networking and the acute infection spike in viral load means that as soon as one person ina network of concurrent relationships contracts HIV everyone else in the network is placed atrisk (UNAIDS, 2008, Focus on Multiple Concurrent Partnerships).


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and support from officials, condom promotion and sex talk became a quotidianaffair:

One friend we nicknamed ambulance because he always hascondoms in his wallet, he says for emergency. One time he jokedfor emergency call, because I am always there to save your lives.So, condoms are sold in every clinic, in supermarkets, shops andhawkers have them. Prostitutes in Kampala charge a condom fee ifyou dont have one (a man in his twenties cited in Schoepf,2003:564).

A Mini-anthropology of Condom Promotion in AfricaShifts in societal attitudes toward condoms parallel with the false starts andsubsequent lessons learned by condom educators. Early condom promotion inAfrica portrayed AIDS as an illness acquired by sex workers and others whoengaged in illicit sexual behavior. There were posters with a guy and a bottle ofbeer and a lady in a miniskirt. Those were the ones that were supposed to getHIV (Nolen, 2007:65).28 Campaigns depicted the sex worker as a reservoir ofinfection, which led to the construction of AIDS as a disease of women and ofthe lower orders something from which the pure needed protection rather than as the thing that should be used when one is ignorant of his or herpartners serostatus i (Schoepf, 2001:341).

Figure 2: Frederick, F.S. (1989), Unknown location

In Zimbabwe an early poster depicted a woman in a miniskirt and highheeledboots, dragging on a cigarette, and the caption exhorted the men to remainfaithful to their families (Bassett and Mhloyi, 1991:150).29 In the DRC, Massmedia campaigns stressed marital fidelity, avoidance of prostitutes and sexualvagabondage as well as clean injection syringes and blood transfusions(Schoepf, 1992:229). Women who wished to maintain their virtue in the eyes of

i Serostatus refers to the presence or absence of specific substances in the blood. In the instanceof HIV, a blood test which indicates the presence of antibodies that the body produces inresponse to HIV infection, indicates that a person is seropositive.


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their male partner didnt dare venture into shops to purchase condoms, or askfor protection. A Zambian woman reiterated this to anthropologists in the field:I have never seen a condom. Why should I use a condom? Condoms are onlyused by prostitutes (Bond & Dover, 1997: 384).30

Anthropologists and other social scientists initiated a movement from riskgroups to risk behaviors and condom programmers, along with that populartrend, began to implement condom social marketing (CSM). Condom socialmarketing works by creating an informed demand for the product througheducation and promotion, and then by ensuring that supplies are accessible tomeet the new demand. International organizations such as UNAIDS, PopulationsServices International (PSI) and the United Nations Population Fund (UNFPA),partner with national governments to procure unbranded condoms that are thenpackaged, promoted, and locally distributed. Condom social marketing acts as anormaliser of condoms, works to reduce stigma and creates an environment in

which condom use is more socially acceptable.

Figure 3: Trust Condom commercial, PSI Uganda31

For example, PSI and the Malawi government introduced theChishango condomin September 1994. The brand means 'shield' in Chichewa and cost MK7.00(US$0.06) for a package of three (PSI Malawi, 2004).32 Since the launch of thelocal brand, condoms sales have continuously increased: In 1994, 4.7 millioncondoms were sold and by 1998 sales reached 7.1 million. In 2003, sales reachedan alltime high of more than 8.4 million.


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Figure 4: PSI Malawi, Chishango condoms advert

While CSM has led to an increase in condom supply and demand, someanthropologists find fault with the western premises for condomising SubSarahan Africa. Bledsoe (1991) notes that international agencies that arescrambling to subsidise and distribute condoms in Africa have failed toappreciate the strength of local beliefs that redefine technologies that outwardlyresemble our own (1991:6). Indeed ethnographic data show that for some, inspite of CSM, the condom represents an unacceptable social distance betweenlovers, illicit sex, mistrust, and a western intrusion into the African conjugal bed.

Other researchers have found that increased condom distribution in someAfrican countries did not coincide with reduced HIV prevalence rates (Hearst &Chen 2004). For example, in Botswana, from 1993 to 2001, condom salesincreased from one million to 3 million, while its HIV rate rose from 27 percentto 45 percent. During the same time in Cameroon, condom sales increased from6 million to 15 million, while HIV rates rose from 3 percent to 9 percent(AIDSMark cited in Hearst & Chen, 2004:41).33 The inconsistent use of condomsis one likely reason for the coexistence of increased HIV prevalence rates andcondom distribution. A second reason for this phenomenon is the theory of riskcompensation: Increased condom use could reflect decisions of individuals toswitch from inherently safer strategies of partner selection or fewer partners tothe riskier strategy of developing or maintaining higher rates of partner changeplus reliance on condoms (Richens, 2000:401). Therefore, for a condompromotion campaign to be beneficial, it must increase condom use substantiallyif the baseline use is low and the total number of sex acts increases (2000:401).

This brings us back to the statements of Pope Benedict XVI: You cant resolve it[HIV] with the distribution of condoms. On the contrary, it increases theproblem (cited in the New York Times, 2009). Regardless of ethnographic andstatistical trends, its unwise to rule out condom promotion in Africa because

condom use reduces the chances for mutations of the AIDS virus, and asubsequent proliferation of strains (de Leon et al, 2009). However, there are


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socioeconomic evidence which anthropologists not a polarizing religiousfigure could offer in the movement to demedicalize HIV prevention in general,and condom promotion in particular. As Durkheim offered, What sciencedisputes in religion is not its right to exist but the right to be dogmatic about thenature of things, the special competence it claimed for its knowledge of man andthe world (Durkheim, 2008:325). In this case, the Vatican and other religiousconservatives are dogmatic in their claims that condoms are ineffective and leadto illicit sexual behavior. While the theologians are correct to emphasize thesocial side of AIDS, religious solutions fail to recognize the impact of poverty,conflict, colonialism, gender inequality, migration, development, and other socioeconomic structures, which hinder abstinence, fidelity and condom use.Anthropology, the most radically contextualizing of the social sciences, is wellsuited to meeting these analytic challenges, but we will not succeed by merelyfilling in the cultural blanks left over by epidemiologists, physicians, scientists,and policy makers (Farmer, 1998:36).34 As condom promotion remains a hotlycontested issue, social scientists must unite with biomedical researchers to getrid of reductionalism both biomedical and cultural and inform condompromotion, while offering a sound analysis on the sociocultural drivers of theAIDS epidemic.


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CHAPTER 2

FEMALE BODIES, MALE CONTROL

While the religious rights assertion that condoms are not the solution to HIV inAfrica comprises a granule of truth, the proposed alternatives of abstinence andfidelity are as equally inadequate in addressing the vulnerability of girls andwomen to HIV infection. AIDS researchers have called HIV a biological sexistorganism because it is transmitted five times more efficiently from male tofemale. HIV is more highly concentrated in seminal fluids than in vaginalsecretions and may more easily enter the bloodstream through the extensiveconvoluted lining of the vagina and cervix. Vulnerable penile surface area is

much smaller in circumcised men without genital ulcerations, only the urethralmeatus is involved (de Bruyn et al cited in Simmons et al, 1996:47).35 Womenand girls are more vulnerable to HIV infection because of their physical bodies,and their relative unequal status in the social body makes the condom a derisorysolution to their precarious situation.

The feminization of HIVAlthough women comprise the bulk of the agricultural labor force, supply mostof the semiskilled and unskilled work, and take on most of the reproductivetasks, which include child birthing and rearing, producing and cooking food,caring for their spouses, and tending to the sick women often lack access toland, credit, education opportunities, health care choices, and politicalparticipation (Meena, 1992).36 It is one thing for a woman to keep body and soultogether by selling cooked food or vending a few vegetables at the side of theroad because the man does not support her, but it is another thing to refuse theman his conjugal rights on the basis of his refusal to wear a condom, which manywomen cannot afford to buy in any case (McFadden, 1992:186).37 Women acceptthe ideology that male partners can dominate their physical bodies, knowing fullwell that men dominate most sociocultural aspects of life and are thegatekeepers to vital economic resources.

While socioeconomic status presents one aspect of womens ability to negotiatethe conditions of sex (including condom use), another formidable opposition isthe socialization of women in regards to how a proper woman responds to herhusbands sexual demands. Many African societies dictate that proper womendont talk about sex, nor do they say no to their husbands advances(Ssekiboobo, 1992).38 In a Uganda study, Wolff et al (2003) found thatparticipants believed that only prostitutes and women who drank alcoholopenly discussed sex. Obbo (1993) writes that traditional premarital sexeducation classes teach young Ugandan women that they should never say no tosexual demands made by their husbands. How can a woman who has beensocialized never to question the male right to have sex with her when he sodesires, as her husband, and who rarely if ever discusses matters of sex, or even


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sees her husband naked, negotiate with him on the matter of condom use?(McFadden, 1992:171). The short answer is, she cant.

Womens disempowerment in negotiating sex and condom use is furthercompounded by physical and emotional violence. Bujra (2000) found that inTanzania husbands sometimes flatly refused to use condoms, and could usephysical violence against wives who made the suggestion. Some men get drunkand they refuse these things, and they can beat you (an elderly woman cited inBujra, 2001:73). Male responses articulated the idea that men exercise authorityover their wifes body: 'A wife who asks you to use those things [condoms] is nota wife but a prostitute'. 'How can a woman decide? She can't order her husbandto do things!' (man cited in Bujra, 2001:73). During the workshop in Lushoto, themagnitude of womens precarious situation was reified, as one middleagedvillage wife, who after hearing that condoms offered protection from AIDS,rehearsed what shed say to her husband:

All right husband, you are home and lets celebrate, but use thatcondom! And if you havent got one, then Ill go and sleepelsewhere! Or if you keep forgetting, then buy them for me to keep!(cited in Bujra, 2001:59)

This rehearsal of womens empowerment, while entertaining to the women atthe workshop, is just that, a comical drama. Women who broach the subject ofsex or condom use with her husband can be beaten on the suspicion of taking ona lover (McFadden, 1992). I will argue that based on such ethnographicnarratives, there is little to presuppose that the condom can protect women from

contracting the AIDS virus. The condom loses its power because genderstereotypes silence women from even speaking about safer sex less they beconsidered a prostitute (Wolff et al, 2000), risk beatings (Bujra, 2000), or faceeconomic disenfranchisement (Schoepf, 1992). The Performance of TrustCondom use in stable partnerships is further imperiled by the risk and trustquandary. Women fear to ask in case they are thought to be infected, or immoralthemselves: he will ask, where have you been?! A wife might ask when sheknows or suspects that the husband is infected. But in raising the issue, sheundermines further the trust in between them. And so, although few womengenuinely trust their husbands, the appearance of trust must be there (Bujra,2000:76). Condoms threaten to dissolve relationships already at risk because ofruralurban migration, insistent poverty, and the social milieu surroundingformal and informal polygany.

Bledsoe (1991) found that a womans suggestion that a male partner wear acondom is the equivalent of accusing him of unfaithfulness, or worse, infectionwith HIV. In insisting on a condom, a woman risks undermining economicsupport from an outraged partner (1991:7). Hence while condoms reduce therisk of HIV transmission, the technology threatens the stability of relationships,

and poor women cannot risk losing the vital economic support of their malepartners.


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In contrast to the situation of poor woman with little economic leverage,research has shown that women with higher socioeconomic status have betteroutcomes in negotiating safer sex (Orubuloye et al, 1993; Wolff et al, 2000).However, this economic independence does not give women an escape from therisktrust quandary surrounding condom use. Comparative research on Ugandaand the DRC found that even high class entrepreneurial women in Ugandafailed to negotiate condom use with their regular partners (Schoepf, 2003). It isnot clear whether these women believed that they were not at risk in theserelationships, whether they felt unable to negotiate condoms due to the trustand respectability issues, or whether a combination of these left them in denial(2003:563). In Uganda, the DRC, Tanzania, and elsewhere in Africa, the beliefthat women must trust their partner is ubiquitous and directly opposes condommessages, which implore individuals to use condoms unless both partners aremutually committed to monogamy. The inverse relationship between risk andtrust is an angle that condom programming could investigate in the targeting ofmessages.

The Risky Sex of Married CouplesIt is important to note the difference between stable partnerships and marriagesbecause the type of union has implications for womens ability to say no to sex,or unprotected sex. Even with such a distinction, marriage is highly varied inAfrican societies. For example, anthropologists would consider at least thirteentypes of partnerships/transactions a marriage in precolonial Dahomey, andMary Douglas 1963 ethnography on the Lele revealed the coexistence ofpolyandry and polygany (Guyer, 1991). In the 21st Century, African marriagesstill retain diversity in its stylized representations. Typically, it [African

marriage] is a process, extending over a period of months or even years, aspartners and their families work cautiously toward more stable conjugalrelationships. At some point in the process, cohabitation and sexual relationsbegin, and children may be born (Bledsoe, 1991: 3).

Gendered expectations of fidelity characterize most African marital unions.jWomen are socialized to be faithful and tolerate their husbands extramaritalaffairs (Bledsoe, 1991; Bujra, 2000; Obbo, 1993; Orubuloye et al, 1991). Eventhough men often have the implicit permission to cheat,ethnographic evidencerevealed that men felt pressured to feign fidelity. Rather than face accusations ofunfaithfulness, the husband would have unprotected sex with his wife even if hehad unprotected sex with another woman (Orubuloye & Caldwell, 1993; Schoepf,1991; BondDover, 1997; McFadden, 1992). Since condoms interrupt the illusionof fidelity, married women are often reluctant to request or accept condom use(Chimbiri, 2007; Schoepf, 1992; Bassett and Mhloyi, 1991). The ambiguousnature of unspoken sexual commitment results in each partners reduced abilityto negotiate condom use. They therefore revert to condomless sex. [As] unsafesex implies closeness, trust, honesty and commitment and leaves rosy facadesand dreams of monogamy and security intact (Green cited in Bujra, 2000:77).

j The use of the term African here is in consistency with the anthropological findings on some of

the common attributes in African marriages. While there are regional and ethnic variations, themulticountry ethnographical accounts offer similar constructions on the gendered expectationsof marital fidelity.


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The riskandtrust charades of married people was explored in three ruraldistricts in Malawi. Research found that while Malawi women have used divorceas an option to protect themselves from HIV, Malawi men have responded byreducing sexual partnerships, being more selective of extramarital partners, andusing condoms in outside sexual liaisons (Chimbiri, 2007).39 To both marriedmen and women, as evidenced with the discussions of mens and womens socialnetworks, the condom for use in unacceptable and suspicious sexualpartnerships (2007:1113). To the women, the condom embodies an intolerablethreat to the marriage and is consistently associated with bad sex: infidelity,transactional sex, and a husbands dissatisfaction with sex at home:

At one time, I found condoms inside the pockets of my husbandspair of trousers. So I asked my husband: What are these thingsfor? He said: I just move with them. I asked him: How do you dothat? He replied: Ah, in case I grab a woman who surrendersherself to me, I do not want to contract a sexually transmitteddisease. At one time, I get annoyed. I took all of the condoms andburnt them. Then he said: So you want me to contract an STI andthen we will all have it. I said to him: Why do you need thesecondoms? Why should you do that yet you have two wives? If youwant a woman, you should just come to one of us. If you feel thatwe do not satisfy you, why dont you just leave us? Then he said:Ok. But after some time, I just realized that he brought somemore condoms (rural married woman, 37, cited in Chimbiri,2007:1111).

Introducing condoms into Malawi marriages also faces cosmological difficulties,as Malawi people believe that marital sex comes from God and compriseselements that should not be altered: 1) Sex is a natural candy to be enjoyed,and 2) Sex is purposed to produce children. As one young married woman said,With a condom, we get nothing. Can you chew a sweet together with its packet?Can you get the sweetness, you cant? So what we want is the whole of the thing(the penis) should enter into me and just that so that we can feel the sweetness(young married woman, cited in Chimbiri, 2007:1111). The symbolic nature ofthe condom interrupts the symbolic nature of marriage, and condoms introducedinto marriage, meant that the union wasnt really a marriage at all. Althoughcondom use has increased for outside partners, when the extramarital partner isconsidered risky, the social construction of marriage makes it unlikely thatmarital condom use will increase anytime soon (Chimbiri, 2007).

The examples from Tanzania and Malawi illustrate that in order for condomstigmas to dissipate the condom must first be socially accepted as a legitimatetool to prevent a potentially fatal illness caused by a microbiological event,nothing else. The Ugandan presidents public promotion of condoms via themass media, and the condoms subsequent acceptance by religious andeducational institutions is one example of how the condom can overcome stigma.Based on applied anthropological outcomes in the DRC, Schoepf (1992) has

suggested interventions, which train couples on communication to assist them inspeaking about their sexual histories, and to help them make a realistic risk


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CHAPTER 3

THE SOCIAL AND COSMOLOGICAL DIMENSIONS OF SEX

Notions of good sex are culturally specific and implicitly tied to personhood.People have sex to experience pleasure, procreate or gain profit. Over the pastmillennia, sex has assumed a complex and varied character, impacted upon byculture, customs, norms of behavior, morals and by the commoditizationprocess (McFadden, 1992:167). In some African societies successful sex andthe condom are diametrically opposed because it diminishes fertility, often theimplicit goal of sex. In Zambia, the condom prevents good sex because itprolongs the sex act, a characteristic of intercourse viewed unfavourably because

longer sex reduces the number of rounds or possible ejaculations.Condoms also prevent the mingling of the male and female sexual secretionsthat are believed necessary for procreation in Tanzania, Zambia and the DRC.Lastly, the condoms principal job of preventing semen from entering the wombinterferes with the vaginal ejaculation of semen reckoned necessary for thewoman to orgasm in the DRC and Zambia. Though these beliefs are highly varied,the findings have one aspect in common: cultural meanings of sex directlyoppose and can prevent condom use even in areas where participants areaware of AIDS and the condoms prophylactic effect. I have chosen Healds(1995) examination of mingling, the East African metaphor for coitus andreproduction, because of its implications for condom promotion and use.

Mingling cannot take place if the couple uses a condom because it requires thewhite blood of semen and the red blood of menses.

In some cases the white blood is seen to effectively fix themenstrual blood inside the woman, and the specific powersattributed to the white versus the red blood vary. However, in itsgeneral form, the belief has three main implications: first, that thechild is formed jointly from the bodily substances of both husband

and wife; second, that repeated intercourse is necessary forconception and for the growth of the foetus in the womb; third,very frequently the most fertile time of the month is identifiedwith menstruation and the days immediately following it(1995:498).46

The use of condoms would interrupt the moral responsibility of both parents todevelop their unborn child, but in situations where an individual has multipleand concurrent sexual partners, or in the case of a serodiscordant couple,mingling greatly increases the risk of HIV transmission.

Representations of semenIn the AIDS epidemic, international health organizations have progressed


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northern biomedical hegemony regarding the construction of AIDS, the symbolicvalue of semen, the meaning and purpose of sex, and the procreative process.Condom promotion literature instructs practitioners to recount that semen isscientifically proven to be a simple biological substance that either impregnatesa woman, or transmits pathogens to her or the fetus. For example, literaturefrom UNFPA (2007) cites: Semen is the fluid that protects and carries the spermto fertilize an egg (ovum) in human reproduction. All men inevitably wastebillions of sperm and liters of semen during a lifetime. They are wasted in acondom, washed out of a womans vagina, or reabsorbed into the mans bodybecause he has not ejaculated. All this is completely normal and does not causeany harm to the man or the woman (2007:49).47

However, notes from the field suggest that many cultures do not share the sameviews as UNFPA, and also do not put much purchase into the use of condoms.Coast (2007) analysed the sociocultural significance of sperm and context ofcondoms amongst the rural Maasai and found that the local populations viewedcondoms negatively because they counter fertility, waste semen, are notMasaai and interrupt the womans sexual pleasure. The Maasai also believe thatsemen is important for the physical growth, and development of the breasts ofan entito a young, circumcised girl (Coast, 2007). Murran [circumcised malewho becomes a warrior] are considered the epitome of healthiness, therefore,their sperm is best for prepubescent girls(2007:11).48 Through sexualinitiation and the giving of semen, themurran is instrumental in shaping societalapproval of the fertility of theentito.

Research participants agreed that it would be impossible to introduce condoms

in the murran-entito relationship; and condoms would be undesirable in mostMaasai contexts because of the highly symbolic value of semen. Coast concludedthat condoms as an AIDS prevention technology amongst the Masaai should bereevaluated and other methods that are more compatible with the culturalvalues of semen should be investigated. Where sperm [and fertility] are highlyvalued, microbicidesm might represent a real alternative to condoms for HIVprevention (2007:22).49

Condoms and good sex dont mixThere are also notions of masculinity, male potency and good sex representedby semen. In Chiawa, a rural chieftaincy in Lusaka Rural Province, semen holdssuch importance that the grandfather (or elder male relative) of a young male isresponsible for initiating a course of potency medicine (usually an herbalmixture), which is continued throughout manhood. In consistency it [semen]should be thick, cream coloured and sticky (Bond & Dover, 1997:380). Thequality is important because its inversely related to the number of ejaculations(rounds), a key component of good sex. The first round holds primeimportance, as this is the time when the mans bullets should penetrate deepinside the woman, an action, which also infers that the primary cultural concern

mVaginal microbicides are proposed as a femaleinitiated method to reduce the risk of maletofemale transmission of HIV and other STIs. Once a viable option is developed the product form

would occur as vaginal creams, gels, foam, or rings (Population Council, 2008).


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with sex is reproduction.

Both men and women agreed that it was insufficient for a man in his prime tohave only one round. An older woman said, More than two rounds showlove; that a woman is good and a man is strong(cited in Bond & Dover,1997:381). The dominant clich retold to anthropologists was that penetrationand vaginal ejaculation without condoms is shorthand for good, proper sex inChiawa (1997:382). Through vaginal ejaculation a man fulfills his procreativerole, sexually satisfies the woman, and perpetuates the cultural value of goodsex although participant responses revealed a conflict between cultural beliefson good sex, constructions of manhood, and wishes to avoid pregnancies orsexually transmitted infections (Bond & Dover, 1997). While the study concludedthat condom promotion shouldnt be completely abandoned, research on themigrant farm suggests that due to culturally specific sexual practices and beliefsconcerning sex, condom promotion should take place alongside other safer sexmethods, (PrestonWhyte cited in Bond & Dover, 1997:388).

To date, the only alternative safer sex methods are abstinence and fidelity, whichleads us back to relying on heroic behavior to prevent HIV. Can the promotionof safer sex lead to sustainable behavior change and subsequent reduced HIVprevalence rates? Or do cultural attitudes regarding sex presuppose the adoptionof sexpositive strategies? Biomedical experts, through the investment of $868millionn in AIDS vaccine research and development in 2008 alone, have impliedthat behavior changes are unlikely to occur at a pace that will slow the rates ofinfection in the AIDS epidemic.50 But anthropologists (Schoepf, 1991; Heald,1995, Obbo, 1993) argue that Africas long history of cultural adaptation in

response to forces such as colonialism and modern warfare should be a strongindication of the continents capacity to address the threat of AIDS. Indeed oneman responded:

They shouldnt think that African men cant change. Thats wrong.Only dont ask the impossible. Men wont become monogamousover night. They [condoms] arent pleasant. Nevertheless, betweenlife and the risk of a horrible death, men like ourselves will chooselife. Its wrong to say we cant change. Since we all wantdescendants, we have to lick AIDS (cited in Schoepf, 1991:752).51

n Figures taken from UNAIDS, 2009.


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CHAPTER 4

THE SOCIAL PRODUCTION OF AIDS

While the cultural premises for condom rejection remains at loggerheads withthe scientific proof for condom promotion, Farmer (1999) cautions against theconflation of cultural practices and structural violence. For example, the Yorubawomen of the Ibarapa District carry out the culturally acceptable practice ofhaving multiple and concurrent sexual partnerships, but this sexual behavior isnecessitated by economic and social need. UNAIDS has cautioned that thispractice in particular places individuals at an increased risk to AIDS because theviral load and 'infectivity' is much higher during the three to four week 'acute

infection' window period that initially follows HIV infection (UNAIDS, 2008).Economically necessitated (informal) polyandry, polyandrous motherhood, andreliance on survival sex are structural factors that make women in particularmore vulnerable to AIDS. This coupled with the physiology of the female bodyconspire to entrap resourcepoor women in a complex web of risk. Thisassumption is supported by statistics from UNFPA, which state that the majorityof individuals living with HIV in the SubSaharan African region are women(UNFPA, 2008).52 UN agencies refer to this alarming trend as the feminization ofAIDS and poverty. Farmer (1996), however, calls their sickness a result ofstructural violence because it is neither nature nor pure individual will that is atfault, but rather historically given (and often economically driven) processes andforces that conspire to constrain individual agency (1996:23).53 In the sectionsbelow I will examine how socioeconomic phenomena such as structuraladjustment programmes (SAPs), urbanrural migration, and mining work coexistwith sexual risk taking implicated in the transmission of the AIDS virus.

The Sexual Consequences of Poverty The oil shock of the 1970s sent many SubSaharan African economies into adownward spiral. Financial institutions were eager to lend as they figuredsovereign entities would not default on loans; but as countries became heavily

indebted, they couldnt repay and had to agree to International Monetary Fund(IMF) designed reforms known as structural adjustment programmes (SAPs).Although there is no unitary SAP, some measures include the introduction ofuser fees for primary healthcare and education, increased interest rates, theprivatization of public enterprises and trade liberalization.

Barnett and Blackwell (2004)54 argue that it is difficult to measure the directimpact of discrete economic variables on HIV transmission rates but thewidespread adoption of SAPs in subSaharan Africa has been synchronic withsignificant increases in HIV prevalence rates (2004:9). For example, increasedinterest rates and the privatization of public enterprises can lead to jobshortages and more women engaging in transactional sex to survive to meethousehold needs. Trade liberalization is often the culprit in reduced subsistence


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While ruralurban migrant men have relied on informal polygany as a copingmechanism, mine workers have responded to the perils of working in the SouthAfrican gold mines by shaping meaningful social identities and masculinities.One man recounted the terror he experienced the first time he rode in the cage(lift) to the worksite located up to 3 kilometers underground. They told me thatin this situation you must know that now you are in the mines you are a man andmust be able to face anything without fear (mine worker cited in Campbell,2004:150). A macho sexuality often accompanied the bravado, fearlessness,and persistence needed to survive in such circumstances. The anthropologistrecorded the following dominant clichs: There are two things to being a man:going underground, and going after women and a man must have fleshtoflesh (mine workers cited in Campbell, 2004:152).

Although the mines launched multiple campaigns that promoted HIV/AIDSawareness and condoms, Campbell (2004)59 posits the stressful and sociallyimpoverished living conditions under which the miners live, contribute toloneliness and less opportunities for meaningful intimate and socialrelationships. These structural factors are manifested in sexual risk taking such ahaving multiple sexual partners without the use of condoms. The sexual risktaking of miners can be compared to the larger risks miners take on the job: Asone miner said, there is no protection from fate: The rock can just fall anytimeand we try not to think about that (miner cited in Campbell, 2004:149). One caneasily juxtapose AIDS, a seemingly uncontrollable fatal syndrome, and thecommon rock accidents, to understand why condoms are of little interest tothose living in dire circumstances that override the invisible threat of the AIDSvirus. Although HIV prevalence rates are typically high in the mines (Campbell,

2004), protecting oneself from infection will remain a lesser preoccupation thanthe warmth and intimacy that fleshtoflesh sex offers to lonesome miners indeplorable living conditions.


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CONCLUSION

Condoms are effective in preventing the transmission of the AIDS virus, however,

ethnographic evidence shows that populations in the subSaharan African regionoften face economic, social and cultural constraints to using condoms. Suchconstraints are often marginalized in the discourse on HIV prevention, where thefocus in placed on the epidemiological patterns of transmission and thebiotechnologies proven to reduce risks. This dissertation is calling for medicalanthropologists to lead the demedicalization of HIV prevention, and to advocatefor a more holistic approach that considers the social side of AIDS.

Anthropologists have the tools to reframe the debate on HIV prevention, andlend support to a new approach. For example, research has uncovered ways thatHIV prevention can work with cultures to promote condom use, and other sexpositive behaviors. For example, research in the DRC suggests that in culturalcontexts where emphasis is placed on lineage, the health of the infant can bestressed as a reason to use condoms with serodiscordant couples, or when onepartner is suspected of being seropositive. This focus would avoid the risktrustquandary, which poses a barrier to condom use in stable partnerships.o

In cultures where bodily fluids hold social and cosmological dimensions, healthworkers could collaborate with traditional healers to reinvent beliefs on the roleof semen in procreation. Applied anthropological work in the DRC found thattraditional healers were able to reinterpret the East African metaphor of

mingling to mean that the father should focus on his wife and not haveextramarital affairs while she is pregnant with the child. This intervention notonly served to reduce the risk of perinatal transmission of HIV, but it alsoprevented the emergence of harmful counter discourses from traditional healerswho might feel marginalized or excluded from the biomedical dominatedHIV/AIDS debate.p

Anthropologists must lobby for the inclusion of interventions, which address thecofactors of HIV transmission, such as gender inequality, on HIV/AIDSprevention research agendas, if Africa is to ever witness atrue decrease in HIVprevalence rates, rather than stabilization attributed to dieoff. In this regard,ethnographic trends support the position of African feminists who state that menare the solution to HIV. In contexts where men hold the social, political, andphysical power over women, the condom, a male applied device, depends on thefull acceptance and cooperation of men. Until the social marketing of the femalecondom takes place, men must be the main targets of condom promotion.

Lastly, the grinding poverty which is common to many African societies withhigh HIV prevalence rates must be addressed by international agencies investedin reducing the illness and death associated with AIDS. Focussing on abstinence,fidelity, and condoms offer very little to women who sell their bodies for

o(Schoepf, 1992)p(Schoepf, 1992)


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1 EPSTEIN, H. (2001) AIDS the Lesson of Uganda.The New York Review of Books,48, 11.2 OBBO, C. (1993) HIV Transmission: men are the solution.Population andEnvironment, 14, 3,21143.3 UNAIDS (2004) Making condoms work for HIV prevention : cuttingedgeperspectives. Geneva, Joint United Nations Programme on HIV/AIDS (UNAIDS).4 UNAIDS (2008b) UNAIDS Report on the Global AIDS Epidemic. Geneva,UNAIDS.5 MORRIS, K. (2008) The ef ect of HIV/AIDS on international healthThe LancetInfectious Diseases, 8, 8,468469.6 UNAIDS (2008a) Country Responses: Regions, subSaharan Africa.7 UNAIDS (2008). HIV prevalence (%) amongst adults, 1549 in Africa, for 2007,UNAIDS Report on the Global AIDS Epidemic. Geneva, UNAIDS.8 RAMIN, B. (2007) Anthropology speaks to medicine: the case HIV/AIDS inAfricaMcGill Journal of Medicine, 10, 2,127132.9 GAUSSET, Q. (2001) AIDS and cultural practices in Africa: the case of the Tonga(Zambia).Social Science and Medicine, 52, 4,509518.10 BROKENSHA, D. (1987) The Social Factors in the Transmission of Control ofAIDS in Africa.Studies in African Health and Medicine, 1,16773.11 PARKER, R. (2001) Sexuality, Culture, and Power in HIV/AIDS Research. Annual Review of Anthropology, 30,163179.12 BOLTON, R. (1995) Rethinking Anthropology: The Study of AIDS. in TENBRUMMELHUIS, H. H., G. (ed.)Culture and sexual risk: anthropological perspectives on AIDS. Gordon and Breach Publishing Amsterdam.13 D'ANDRADE, R. (1995) Moral Models in Anthropology.Current Anthropology,36, 3,399408.14 Malinowski, B. (1961) Argonauts of the Western Pacific, Dutton: New York, p.25.15 AP (2009) Pope, in Africa, Says Condoms Arent the Way to Fight H.I.V. .TheNew York Times Online. New York, The New York Times.16 BRADSHAW, S. (2003) Vatican: condoms don't stop AIDS.Guardian,. London.17 UNAIDS (2004) Making condoms work for HIV prevention : cuttingedgeperspectives. Geneva, Joint United Nations Programme on HIV/AIDS (UNAIDS).18 FOUCAULT, M. (1976) The Biopolitical. in BERTANI, M., FONTANA, A, &EWALD, F (ed.)Society Must Be Defended: Lectures at the Collge de France.Penguin Books London.19 AP (2009) Pope, in Africa, Says Condoms Arent the Way to Fight H.I.V. .TheNew York Times Online. New York, The New York Times.20AUTH, T. (2009) Blessed are the sick, for they have not used condoms.Philadelphia, Philadelphia Inquirer.21 DE LEON, S. P., JIMENEZCORONA, M. E., VELASCO, A. M. & LAZCANO, A. (2009)The Pope, condoms, and the evolution of HIV.The Lancet Infectious Diseases, 9,8,461462.22 http://www.washingtonpost.com/wpdyn/articles/A294042005Jan22.html23 UNAIDS (2004) Position Statement on Condoms and HIV Prevention. Geneva,UNAIDS.


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24 DURKHEIM, . (2008)The Elementary Forms of Religious Life New York, OxfordUniversity Press.25 OBBO, C. (1995) Gender, Age and Class: Discourses on HIV Transmission andControl in Uganda. in TEN BRUMMELHUIS & H. , H., G. (ed.)Culture and sexualrisk : anthropological perspectives on AIDS Gordon and Breach PublishingAmsterdam.26 BUJRA, J. (2000) Risk and Trust: Unsafe Sex, Gender and AIDS in Tanzania. inCAPLAN, P. (ed.)Risk Revisited Pluto Press Sterling.27 SCHOEPF, B. G. (2003) Uganda: Lessons for AIDS Control in Africa.Review of African Political Economy, 30, 98,553572.28 NOLEN, S. (2007) 28: stories of AIDS in Africa, London, Portobello Books.29 BASSETT, M., & MHLOYI, M. (1991) Women and AIDS in Zimbabwe: themaking of an epidemic.International journal of health services : planning,administration, evaluation, 21, 1,143156.30 BOND, V., & DOVER, P (1997) Men, women and the trouble with condoms:condom use by migrant workers in Zambia.Health Transition Review,7,Suppl:3779.31 PSI Uganda. Trust Condoms. Retrieved 8 September 2009 fromhttp://www.youtube.com/watch?v=ypE89iMQsb0.32 PSI Malawi (2004)Chishango Condoms . Retrieved 10 September 2009 fromhttp://www.psimalawi.org/chishango.html .33 HEARST, N. & CHEN, S. (2004) Condom Promotion for AIDS Prevention in theDeveloping World: Is It Working?Studies in Family Planning, 35, 1,3947.34 FARMER, P. (1998) AIDS and Social Scientists, critical reflections. in BECKER,C., DOZON, JP, OBBO, C., & TOUR, M. (ed.)Experiencing and Understanding AIDSIn Africa. Codesria, Karthala & IRD Paris.35 SIMMONS, J., FARMER, P, & SCHOEPF, B (1996) A Global Perspective. inFARMER, P., CONNORS, MARGARET, & SIMMONS, JANIE (ed.)Women, Poverty,and AIDS. Common Courage Press Cambridge.36 MEENA, R. (1992)Gender in Southern Africa: Conceptual and TheoreticaI lssues,Harare, Sapes Books.37MCFADDEN, P. (1992) Sex, Sexuality and the Problem of AIDS in Africa. inMEENA, R. (ed.)Gender in Southern Africa: Conceptual and TheoreticaI lssues.Sapes Books Harare.38 SSEKIBOOBO, A. (1992) Women's Social and Reproductive Rights in the Age ofAIDS. Kampala, Paper presented at the Workshop on AIDS and Society.39 CHIMBIRI, A. M. (2007) The condom is an [`]intruder' in marriage: Evidencefrom rural Malawi.Social Science & Medicine, 64, 5,11021115.40 MAKINWAADEBUSYOE, P. (2001) Socicultural Factors Affecting Fertility inSubSaharan Africa New York, DESA, UNFPA.41 CAROVANO, K. (1991) More than mothers and whores: redefining the AIDSprevention needs of women.International Journal of Health Services, 21, 1.42 GUYER, J. I. (1990) Changing Nuptiality in a Nigerian Community:Observations from the Field.Working Paper in African Studies No. 146 .43 Caldwell, J.C. and Roberts, S.Toward a Restatement of Demographic TransitionTheory. Population and Development Review, 2,3&4, 321366.44 Cain, M. (1984)On Womens Status, Family Structure, and Fertility inDeveloping Countries. Washington, D.C. The World Bank.


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Documents

HIV, Poverty, and Sex in Sub-Saharan Africa: Why the Condom Does Not Protect Women from the AIDS Virus