Do you want the good news or the bad news first?

How about the good news…

Yes! An AIDS vaccine! Well – kind of. South Africa just announced this Monday, July 20, 2009, that the first clinical trials are underway for the first ever AIDS vaccine created by a developing country. The United States will be helping with this process.

This is great news for the world, but is especially redeeming for this country that lies on the southern tip of the African continent (hence the name South Africa). South Africa is known for its gloomy statistics when it comes to HIV results. It has the largest number of HIV infectees in the world – 5.2 million. Since the inception of the HIV epidemic, nearly 1.8 million people have died in South Africa. The average life expectancy is 54 years old; however, without the AIDS epidemic many say it would be closer to 64. One of every two teenagers is not expected to reach the age of 60. During the period when AIDS was ‘ignored’ by the South African government, between 2000 and 2003, the country dropped 35 places in the Human Development Index (a scale that ranks the level of development a country achieves). Nearly 70% of all medical expenditures are spent to care for HIV-positive patients.

One statistic that proves intimidating is that nearly one third of women aged 20-34 are infected. These women, at the height of reproductive age, not only have an incredible risk of infected sexual partners, but also passing on the viral infection to their children. While there are certainly mothers out there giving birth at an age younger than 20 or older than 34, it is very likely that a large percentage of child births are of HIV infected mothers.

These trials include 36 healthy volunteers, a significantly larger number than the 12 volunteers who participated in a US trial earlier this year. South Africa’s reputation is on the line. Nearly $31.2 million funds this vaccine initiative that has lasted nearly 8 years. 250 scientists and technicians have invested their time.  In 2007, another vaccine was tested here. The results were astounding – in all the wrong ways. People who received the vaccine presented a higher likeliness to contract HIV than those who weren’t inoculated.

Now that’s the good news. Here’s the not-so-good news…

However, on the same date, the South African government announced that it has halted its support for this research project due to the lack of funds. Currently, the only funds supporting the trial are coming from the United States. Still, the future for such research is threatened. Worldwide, HIV vaccine research has decreased between the years of 2007 and 2008. Many question the cost-effectiveness of creating a vaccine and think the monies would be better spent on prevention and education programs.

While on the topic of South Africa and thinking about the future of the HIV/AIDS epidemic, I looked back into the history of this disease within South Africa. It’s story (like many others) is unique and lends some interesting views about how politics and culture often intersect with disease and medicine.

A Recent History of AIDS in South Africa.

When looking at the dismal track-record of HIV awareness in the 1990s and early 21^st century, one would expect the high cost of this present-day epidemic that we now witness. The first HIV infection appeared in 1982. Prevalence rates of HIV in pregnant women were only 0.8% in 1990 but began to grow exponentially over the next thirteen years – in 2003 the prevalence rate was 27.9%! How could a government let this happen? During this time when South Africa was experiencing its most severe increase of HIV, it was also undergoing major political change. Attention focused on these political rifts instead of the disease, allowing it to spread silently throughout the populace.

After the political scene calmed down, President Thabo Mbeki consistently denied the link between HIV and AIDS between the years of 2000-2003. He was once quoted, “Personally, I don’t know anyone who has died of AIDS. I really honestly don’t.” Mbeki denied the prevalence of this disease despite the AIDS-related deaths of both spokesman Parks Mankahlana and ally Peter Mokaba. His colleague and cohort, Health Minister Manto Tshabalala-Mismang, never trusted conventional anti-AIDS drugs and often refused to provide effect anti-HIV treatment. Instead, she promoted beets and lemons as cures for AIDS. For those who spoke against the government, like 2006′s deputy health minister Nozizwe Madlala-Routledge, the president stripped them of their duties.

The cost of this ‘denialism’ estimates that 330,000 died and 35,000 infants were infected between 2000 and 2005 because of a failure to provide effective treatment. A Constitutional Court ruling was the only reason why anti-retrovirals for mother-to-child transmission prevention (MTCTP) were approved; otherwise, a strong resistance against approval would have prevented such administration.

The strong hatred against antiretrovirals seen throughout the Mbeki presidency has made a significantly negative impact upon the epidemic today. Since then, the government’s roll-out of anti retrovirals has been slow, even as drug companies dangled free or heavy reductions on prices for antiretroviral drugs. 2003 was the first year where these drugs were approved for the public. Since Mbeki was ousted from power in 2008, the period South African HIV/AIDS denialism has ended. Still, a new presidency will not automatically guarantee a successful HIV/AIDS treatment program as several cultural and social factors act as barriers towards HIV/AIDS management.

It’s interesting to contrast our understanding/perception (as a developed country) of HIV/AIDS differs from that of another country. After the epidemic began killing off noticeable amounts of victims, especially pregnant women, cultural perversions blamed women for being sexually ‘out-of-control’ and responsible for the transmission of this infection (Also, note how the South African’s perspective views this as a heterosexually transmitted disease, diametrically opposed to the US opinion of HIV being a ‘homosexuals’ disease). To harness this transmission, such measures like virginity testing were attempted and often supported by the higher echelons of the government.

There was, however, a surprising advocate for this testing – the older women of South Africa. It makes sense though – these women were raised in a culture that rigidly supported chastity before marriage and additionally, these women were handed the burden (socially, emotionally, and financially) of caring for grandchildren whose mothers have died of AIDS. I will not critique this program with respect to the issue of women’s rights; however, there are other reasons why this program may have provoked further HIV/AIDS infections. By placing the blame of the infection on women, men no longer felt responsible for the transmission of this disease. Without regards for their import role in the epidemic, men did not feel the need to protect themselves or their partners and unfortunately, may have unleashed an unyielding wave of new infections throughout the populace.**

Males, in fact, play a great role in the transmission of this disease ( as well as the women… I am not denying them of blame either) as a result of the economic and industrial standards seen in South Africa. Several areas in Africa are economically dependent on their mining sector and often witness high rates of HIV prevalence. Why? It is typical for these gold mining companies to recruit hundreds of thousands of men from rural areas of various countries. These employees were not allowed to bring family with them and signed annual contracts that forced them to migrate to and from work at least once a year. This back-and-forth travel, alongside other seasonal employment opportunities in factories and farms, created ideal migrancy patterns predicting a wide and rapid spread of the virus.

In general, there is a lack of awareness and a self-exceptional belief of immunity seen throughout the population. Only 20% of men and women thought they had a good chance of being infected, suggested by once such study. This study also showed 28% of men who believed they were at no risk of infection actually carried the HIV virus! The lack of awareness about the disease is even apparent through the comments of Deputy President (and head of National AIDS Council) Zuma when he was on trial for raping a woman in 2005. Despite knowing that she was HIV-positive, he said he had unprotected sex and took a shower afterwards to ‘cut the risk of contracting AIDS.’ (For those interested in the result of the case, he was acquitted and was recently elected president as the ANC claimed victory in the 2009 elections)

Many more factors contribute to the epidemic, some of which are artifacts of the infamous South African apartheid including poverty, inequality, and social instability. It was in the 1980s where a State of Emergency was declared as a result of riots over the system of racial segregation experienced since the 1950s. Apartheid had created chasms between ethnic groups both ideologically and physically. Other factors contributing to the epidemic are, but not limited to, sexual violence, disparities in health care, poor leadership in response to the epidemic, and the lack of knowing one’s own HIV status because STI’s are viewed as taboo in African culture.

A Final Word

It is evident that South Africa has experienced a turbulent battle against the HIV virus since the first reports surfaced in 1982. Many years of neglect and decided ignorance allowed the virus to grow from a negligible problem into a roaring, vicious killer. Many factors stemming from cultural/social beliefs and the Apartheid period acted as barriers towards a robust HIV/AIDS program in the country. The introduction of this vaccine trial marks a new period for HIV/AIDS in South Africa but a lack of funding may encourage its brevity. The success (or failure) of this vaccine will be the deciding factor. Regardless of the trial’s result, a push for HIV awareness programs is necessary to stave off further prevalence of the disease.

**As I pointed out before, AIDS in Africa is categorized as more of a heterosexual disease and also, due to the fact that AIDS prevention is targeted through women, I conjectured that men may not feel as if they play a large role in the transmission of AIDS. In the cross hairs of these two culture contexts, a little snippet was posted in the NY Times on Tuesday, July 21^st 2009 titled “AIDS: Role of Gay Men in Spreading Virus is Ignored in Africa Study Finds.” This is something I overlooked in my interpretations but is obviously one of the many reasons why the epidemic in South Africa – and all of Africa -  is so large. In short, a new study shows that gay men have less access to prevention and care (actually, NO money is allocated to gay men in most African countries as homosexual sex is illegal in 31 African countries, resulting in the death penalty in 4). Here, we see almost a denialism of homosexuality that triggers false rumors such as “gay sex and/or anal sex is safer than heterosexual sex.” It may be these rumors that convince gay men to engage in risky sexual behaviors – no wonder men who engage in homosexual behavior show considerably higher infection rates than other men in their respective countries.

Works Referenced:

Williams BG and Gouws E. “The Epidemiology of Human Immunodeficiency Virus in South Africa,” Philosophical Transactions: Biological Sciences © 2001

BBC World News. “SA’s Zuma ‘showered to avoid HIV.’ 5 April 2006. BBC World News. http://news.bbc.co.uk/2/hi/africa/4879822.stm Accessed 20 July, 2009.

Nattrass N. “AIDS, science, and governance: the battle over antiretrociral therapy in post-apartheid South Africa.” AIDS and Society Research Unit Paper, University of Cape Town. 19 March 2006.

Leclerc-Madlala S. “Virginity testing: Managing sexuality in a maturing HIV/AIDS Epidemic.” Medical Anthropology Quarterly, New Series, Vol. 15, No. 4, Special Issue: The Contributions of Meidical Anthropology to Anthropology and byond (Dec., 2001) pp. 533-552.

Chigwedere P, Seage GR, Gruskin S, Lee TH, Essex M (October 2008). “Estimating the Lost Benefits of Antiretroviral Drug Use in South Africa”. Journal of acquired immune deficiency syndromes (1999). doi:10.1097/QAI.0b013e31818a6cd5

Fact Sheets on HIV/AIDS, from the Centers for Disease Control

This post was written by melissa.frick

Tags: aids, global health, hiv, south africa, vaccine

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