Gray clouds sweep over the mountains around Blantyre, Malawi, bringing raindrops that tap at the windows of the men’s ward in Queen Elizabeth Hospital. Inside, a young man sheepishly removes his shirt as a doctor and two medical students arrive at his bed. A brief exam reveals thrush, shingles, and wasting, and the med students diagnose a classic case of HIV. The doctor, Claire Scarborough, nods in agreement. Later, she estimates that 80 percent of the patients are HIV-positive. Many of them look young.
The latest figures indicate that AIDS is increasingly concentrated among young people. The UN Population Fund’s annual State of the World’s Population report notes that half of all recent HIV infections occur among those between the ages of 15 and 24. The trend is most severe in sub-Saharan Africa, where nearly nine million young people have HIV or AIDS.
People like 19-year-old Catherine Banda are affected the most. According to UNAIDS, young women in parts of sub-Saharan Africa are infected at twice the rate of young men. Scarborough summed up her experience: “The women are presenting with AIDS earlier than the men – not by choice, mind you.”
Catherine lives in Malawi, a sliver of a country straddling the Rift Valley in southern Africa, where 15 percent of the 11 million residents are HIV-positive. To meet her, I drive south from Blantyre. The countryside soon opens to rolling tea fields that stretch toward Mount Mulanje’s gray hump on the horizon. The roadside teems with people, carrying bundles on their heads or on the backs of bicycles. Turning off the paved strip of asphalt, two ruts in the red loam eventually lead to a few dozen mud-brick dwellings. This is Kwanjana.
Catherine is waiting. Tall and slender, with short hair and sleepy eyes, she wears a yellow dress and flip-flops that scrape the floor. In a soft voice, she says both her parents died when she was 15, leaving her to care for two younger sisters. To get a job at the tea estates, the men operating them expect sex, she explains.
“If you don’t have food, you must ask for help,” she says. “A person cannot accept food without exchanging sex.” At 16, while seeking treatment for a recurring fever, Catherine learned she was HIV-positive.
Lack of economic and social empowerment has made women especially vulnerable to HIV, a matter that has recently entered the public forum. For example, at a rally outside a health clinic near Kwanjana, local parliamentarian Bob Khamisa gave a stirring speech, urging his constituents to be faithful or abstain from sex.
Afterward, he acknowledged that Malawi’s grinding poverty forces the hungry to make difficult decisions. “Women cannot feed their children, so they are promiscuous,” he said. “They sleep around for food.”
While expressing hope that international aid will alleviate the effects of the epidemic, Khamisa also seemed troubled. “So many people are dying,” he said. “This HIV/AIDS is going to wipe out everything we’ve done since 1964,” the year of Malawi’s independence.
International donations to combat HIV/AIDS have increased dramatically during the past five years, but not enough has been raised to meet the enormous need. Drug treatment to prolong the lives of those with HIV is mostly inaccessible to sub-Saharan Africans. At Queen Elizabeth Hospital, for example, antiretroviral drugs cost the equivalent of $11 per day, a small fortune in a country where the average annual wage is $160.
In South Africa, too, treatment remains elusive, despite the continent’s largest economy and the world’s worst HIV epidemic – 5 million people. In 2003, South African President Thabo Mbeki announced a plan to provide low-cost antiretroviral drugs nationwide. However, this came after years of controversial government inaction and intense lobbying to make drugs available by advocacy groups like the Treatment Action Campaign (TAC).
In an effort to extend drug treatment to millions of South Africans who need it to survive, TAC has sued the government and organized civil disobedience campaigns. Pholokgolo Ramothwala, TAC’s Guateng provincial coordinator, blames the lack of treatment in part on government incompetence, but also implicates the US for supporting international patents on lifesaving drugs. Since only a few companies can legally manufacture these drugs, costs remain high.
During a visit to South Africa in 2003, President Bush pledged $15 billion in AIDS relief over five years to 12 countries in sub-Saharan Africa. Yet, little has been approved so far, and experts agree that even the full amount won’t be more than an emergency stopgap. South Africa is on the list; Malawi isn’t.
Moreover, the US has been accused of creating obstacles to affordable antiretroviral drug therapy for developing countries. At the International AIDS Conference during July 2004, French President Jacques Chirac referred to a US practice that encourages some countries to drop generic antiretroviral drug programs in exchange for free trade, calling it “blackmail.”
Fatalism and Hope
In the absence of treatment, Lovelife, an NGO intent on reducing HIV among South Africans from 15 to 20 years old, has focused on prevention. This age group is key, since 40 percent of South Africans are under 20.
Funded mostly by the Henry J. Kaiser Family and Bill and Melinda Gates foundations, Lovelife is known nationwide for its advertising campaign on billboards, buildings, and the sides of buses. A large ad at Durban’s airport proclaims, “Everyone he’s slept with, is sleeping with you.” A photo shows a man’s bare back being touched by the delicate fingers and painted nails of several women.
Another Lovelife strategy is peer outreach through youth centers in Black townships such as Gamalakhe, a community of 66,000 tucked among low rolling hills near the Indian Ocean in KwaZulu Natal province. Zodaa, 19, is one of the peer educators here. She organizes basketball games and other activities inside the one-room center, and promotes positive self-esteem and steering clear of HIV.
When asked about the future, Zodaa replies, “AIDS is here. We are not all going to be HIV-free. It’s like a war: Some are going to die.”
Her fatalism may come from working next to Gamalakhe Health Clinic, which serves 500 patients per day. During one recent month, 203 patients arrived with clinical AIDS (visible symptoms), while 184 others received treatment, and 84 more tested positive for HIV.
Reflecting on these statistics, Namile Sadaki, chief professional nurse at the clinic, inveighs against a mindset common among young people. “Knowing about HIV/AIDS, and still having more than one girlfriend,” she says. “Why is that? I think it’s in our culture. Nine wives, three and four girlfriends
“If I’m a girl in school, I will not be in love with a schoolboy,” she explains. “I will go to those that can buy me something and give me money.”
Outside the clinic, it is a beautiful day under a big, blue African sky. From near the basketball courts, I see over the corrugated metal rooftops of Gamalakhe to the ocean. My head swims with the many causes ascribed to the AIDS epidemic. I think about how HIV thrives in places of privation – among the hungry in Malawi and throughout a region without access to treatment – as well as in South African townships, where economic and recreational opportunities are scarce.
Yet, something Zodaa said leaves me with some hope. “We can change the future, but it all starts here instead of waiting for some miracle to come.”
Matt Higgins is a freelance writer based in New York City. His writing has appeared in the Village Voice, High Times, ESPN Magazine, and other publications.
UNICEF provides maps, statistics, charts, and country fact links about HIV/AIDS and the young at www.childinfo.org/eddb/hiv_aids/young.htm . The UN Food and Population Fund focuses on sub-Saharan Africa, attempting to identify causes, at http://www.unfpa.org/africa/hivaids.htm . Links to articles on AIDS and the young in Africa also can be found at Canada’s National Union of Public and General Employees, http://www.nupge.ca/issues/aids.htm ; and at the Centre for the Study of Aids at South Africa’s University of Pretoria, www.csa.za.org . Information is available from the Population Reference Bureau at http://www.prb.org .