HIV/AIDS prevalence in Southern Africa has remained high in the last decade and it is a very important indicator of the state of the epidemic in the region. There are several demographic factors that play a critical role in the sustaining of this condition in Southern Africa and this paper will explore the correlations between these factors and the epidemics, causes and impacts of demographics on the spread and tackling of the most serious epidemic in the world.
It is estimated that 24.5 million of the 34.3 million infections around the world are in Africa and in 2000 8.57% of African adults were infected with the disease (Whiteside 2002.) This is the highest rate of infection in the world and Africa is considered to be the epicenter with 26 of the 28 worst affected countries.
Source: World Health Organization
This paper will seek to explore the links between demographic indicators such as poverty rates, gender inequality, income inequality and the prevalence and spread of HIV. It also contains a section on the changing demographics of the population infected with HIV. The paper will demonstrate the detrimental effects that poverty and gender inequality cause on the population.
Poverty and Aids
Source: UN Africa Renewal from data in UN Department of Economic and Social Affairs, The Inequality Predicament, 2005
As the figure above shows, poverty has been steadily rising in Africa for the last 3 decades with the people living on less than a dollar a day increasing from about 280 million in 1980 to 530 million in 2005. Poverty has grave implications for the HIV /AIDS infected. Poverty does not only include the lack of money but the skills and assets required to make money as well (Mbirimtengerenji 2007.) The lack of both monetary and non monetary resources that make it impossible to get out of this poverty is widespread in Southern Africa. It is evident that HIV infection is most prevalent among the poorest in Africa and it is hard to reach the poorest with information, educations and counseling activities to help them deal with or slow the spread of the epidemic (Mbirimtengerenji 2007.) The poor also have very little means to put into action what they are told will help and do not have any reason to do so, even if they do understand the implications of the knowledge imparted onto them. Many of these factors are also increased in their effect due to the income inequality between genders in the region with the poor being more susceptible to abuse by the rich in sexual transactions.
HIV Prevalence by Wealth Quintile in Eight African Countries (Percentage of Adult Population)
Source :Pmed Journal
There are several risky behaviors that poverty makes people more prone to and these behaviors heighten the chances of spreading the disease. These behaviors include, but are not limited to migration, sexual trade, polygamy and teenage marriages. Extreme poverty leads young women to participate in sexual trade which may be the only option to access money for most of these women. These groups of commercial sex workers have been critical in the spread of the disease (Mbirimtengerenji 2007.) The worrying development is that the rate of women involved in such activities is only rising and shows the ineffectiveness of HIV/AIDS prevention or awareness programs on the poorer sections of society.
Migration to find work away from their home has driven many African men away from their wives and families. It is a cultural norm to indulge in sexual relationships outside their marriages in the cities that they have been forced to move to, to find work. This has happened in Zimbabwe, where dire economic conditions have forced men to move away from their families in search of work (Mbirimtengerenji.) The women left behind in Zimbabwe have no way to make money other than to get involved in prostitution and separated and divorced women often have no other choice but to have sexual relationships to survive socially and economically. Even women who are not involved in the sex trade all the time may find themselves in situations where they have to exchange sex of necessities occasionally. This culture has and will lead to an environment where the disease is spread unhindered.
Most of these sexual transactions are carried out unprotected as the parties have no incentive or no means to observe safe sexual practices (Mbirimtengerenji.) It may be the case that they do not take the threat seriously due to the fact that their immediate problems that stem from poverty seem more important to them at that moment. There is also a culture of men paying a lot more from sex without a condom which tempts these young women to indulge in it (Mbirimtengerenji.) Studies show that poverty is the direct cause of commercial sex activity in Swaziland and a third of the commercial sex workers got involved in the work to supplement their income (Tobias.) South Africa also faces similar problems and the prevalence rate was 33.4% in the country by 2005 and many women would transition from work in the garment factories to commercial sex work to increase their income (Tobias.)
Many women in Africa like the ones in Malindi, Kenya also cater to foreigners who pay more and often in US dollars and usually insist on not wearing a condom which further exacerbates the problem. Many young women find European boyfriends as soon as they grow breasts as a means out of their poverty and this means that younger girls in the region are extremely susceptible to the disease (USAID.)
Polygamy is also a cultural norm in many parts of the region and the supporters claim that it ensures the continued status and survival of widows and orphans in an established family structure. This is a long standing tradition in Swaziland where 69% of the population live below the poverty line and this is one of the key causes of the 42% HIV infection rate in the country (IRIN News.) Similar trends can be seen in Botswana where men are allowed to marry multiple women in exchange for a dowry and where one in three people between the ages of 15 and 49 are infected with HIV (IRIN News.) This kind of tradition is hard to break and will remain a key cause of the spread of HIV.
Teenage marriage is also very prevalent in Southern Africa where teenage girls are routinely forced into marriages while others are too young to make informed decisions about the consequences of the union (Clark.) This means that they are at high risk of being infected. The reason that many girls get married young is the fact that it may be the only way for their economic survival and often they think it is a way to prevent themselves from being infected with HIV which is not the case at all. Parent think that marriage is the way to protect the adolescent girls from sexual misconduct and the associated risks while research suggests the contrary. The prevalence of poverty in the region means that parents think that marriage is the only way to secure the financial future of their daughters and therefore try to get them married as soon as possible (WHO.)
Migration, as a result of poverty is also instrumental in the spreading of the disease. When there are no opportunities available locally, people have no choice but to migrate to seek out jobs and opportunities to make money. This can from poverty or from the many civil wars that start in Africa, however most of it is due to poverty (Mbirimtengerenji.) With no food, clothes or shelter, these people have no choice but to get involved in prostitutions to provide for themselves. This increases their risk to exposure to HIV and contraction.
Gender Inequality, Poverty and HIV
Map of OECD Index of Gender Inequality
Source: OECD
Gender Inequality is a major problem in Southern Africa and is considered one of the key aspects in the spread of HIV in the region. The problems outline above that come from poverty are accelerated due to the lack of power of women in the African society. Women have no power in sexual interactions and transactions which mean that they are more likely to engage in risky behavior to appease the demands of the men and this power is wielded with financial psychological and physical violence (Jewkes, Levin, Penn-Kekana.)
There is a large problem in Africa of the lack of discussion of HIV problems and women suggesting use of preventative measures like condoms to men (Jewkes et al.) Jewkes, Levil and Penn-Kekena find in their research that there are age differences between partners, financial abuse, experience of intimate partner violence prior to the past year, and the woman’s assessment of the goodness of the relationship all play important roles in the breakdown of communication that means that women can't demand condom use from men. More educated men and women talk more about HIV while uneducated ones don't and in a region rife with low education, this is a real problem. These factors were directly related to the rates of HIV with people with lower likelihood of discussion of HIV likely to have a greater chance of contracting HIV.
Sexual violence against girls is often used as a military tactic in the many civil wars that plague Africa and this greatly increases their chances of contracting HIV (Human Rights Watch.) There are no policies in place to protect the rights of these women. Girls not being educated at the same rate at boys, lack of legal protection against discrimination and exploitation result in them being put in situations where the only resource they have is their sexuality (Human Rights Watch.)
There is also a great market in child trafficking with girls being targeted more than boys (Human Rights Watch.) This is especially prevalent among orphans who are taken with promises of being given schooling or work but instead shipped off to foreign countries to be used as sex workers. Even girls who are trafficked for domestic work purposes are put in environments where they are likely to be subjected to sexual violence.
Girls who stay in school are also not completely insulated from the risk of sexual violence as they may face sexual abuse in school or on their way to or from school (Human Rights Watch.) Married women may face violence if they demand use of condoms or refuse sex to their husbands and very little is being done to stop this gross injustice. Divorce laws are set up in such a way that it makes leaving abusive relationships very difficult for these women and most African countries do not have laws against marital rape.
Women are often stopped from inheriting property and evicted from lands and homes by their husband's families and may have to engage in sexual activities to keep their property or to provide for themselves (Human Rights Watch.) There are very few laws to protect their property rights and as such is another shortcoming in policymaking to protect women's rights.
Changing Demographics of HIV infected population.
It is becoming evident that the onset of drugs to combat HIV has meant that the infected population is living longer and the first ever study on people older than 50 was published by UNAIDS recently (2013.) They observe that 3.6 million people worldwide aged 50 and above are now infected with HIV and this number will only increase in the coming years. Although the rates of older people with HIV are much higher in high income countries with 30% of the infected population 50 or above, 9% of the infected population in Sub-Saharan Arica is also part of this age group and will require changes in the direction of treatment and care. There are also other factors that are contributing to this shift in demographic. Along with the increased effectiveness of treatment, a smaller proportion of HIV incidence among younger adults is causing the burden to shift towards the older population and the risk behavior that is seen in younger adults which can increase exposure to HIV is also exhibited in older people.
With this change in the demographic, comes new challenges as the risk behavior in older people is markedly different from younger people (UNAIDS.) This means that more research needs to be done to the types of risk that this portion of the population is exposed to and find ways to combat them. Older people are also less likely to get tested for HIV than younger people, meaning that catching the disease in them will be harder without raising awareness and convincing them to get tested. They are also more likely to have other non communicable diseases that will mean that their challenges of coping with HIV will be even greater. A study in South Africa found that 30% of people in this age group had two or more chronic diseases making it harder to treat them for HIV and making sure that they survive the illnesses. Screening services such as tuberculosis screening services also need to increase their access to older people to better cater to the needs of this age group. Biologic factors such as the thinning of the vaginal wall after menopause which increases the risk of lesions and tears also puts older people with high levels of sexual activity at greater risk of contracting HIV (UNAIDS.)
The success of the antiretroviral therapy also bring with it a peculiar side effect. People with HIV living longer greatly increases their chances of infecting others with the disease and this will mean that there may be a spike in infections as more people start to live longer with HIV.
The Actuarial Society of South Africa, which releases projections of demographic changes in their recent model has predicted that antiretroviral treatment will increase the number of people living longer with HIV increasing (2011) but asks for caution is overestimating the success of these treatments. The report also states that the ratio of untreated to treated men is much smaller than the ratio of untreated to treated women but more women than men are receiving treatment due to greater access to HIV screening and care through antenatal services. The lower estimated AIDS mortality rate has also meant that the levels of AIDS orphanhood has decreased as parents with AIDS are living longer to care for their children.
Research by Johnson and Dorrington (2006) confirm these predictions with the prevention and treatment programs modifying the demographic impact on HIV patients. The prevention programs have had a modest impact according to the study while HIV incidence has shifted a bit from younger to older ages. The rate of decline in life expectancy has slowed significantly and there are significant age variations in HIV prevalence, morbidity and mortality due to the changes in the prevention and treatment responses. The effectiveness of the different programs vary from time to time and the study advocates for more frequent studies and observations made on the demographics of the infected population and the effect that the different treatments and programs are having on each section of the population (Johnson et al.) This will better prepare the policy makers and program directors in handling the epidemic and responding quickly to the changing face of the problem.
Conclusion
It is evident that demographic factors play a key role in the spread of HIV in Southern Africa and the world. Poverty forces many to take risky steps that greatly increase their chances of contracting HIV and the gender inequality prevalent in African society only creates more opportunities for women to be in situation where they are exposed to the disease. Factors like migration, polygamy and teenage marriages all put women at risk of contracting the disease as they have access to very little education or knowledge of the implications or consequences of these acts. Poverty forces women to engage in sexual activities to provide for themselves and misconceptions like the prevalence of the myth that marriage will protect against sexual misconduct are rampant in the region and in most cases marriage increases their chances of contracting AIDS.
There is a great oversight in policy making that supports the rights of these women and offers them legal and financial protection against sexual bullying. The spread of the disease cannot be slowed or stopped without addressing the factors that drive these risky behaviors.
The changing demographics of the infected will also mean that the programs and treatments will have to adapt to the new situation and this means that more frequent studies need to be conducted to keep track of these changes so that policy makers can make these shifts quicker to make sure the disease is being handled properly.
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