Social and cultural aspects of the AIDS pandemic

Introduction: the spread of HIV/AIDS in Kenya The AIDS pandemic is a "little short of a national calamity ... crying out to be adequately addressed." This quote is taken from an issue which Wajibu published eight years ago on "AIDS in Kenya." Today, AIDS is a national calamity, almost a "biological holocaust." The just concluded 2nd National Conference on HIV/AIDS and STDs in Kenya gave us the statistics. The picture is grim: the estimate of HIV-infected persons in Kenya is close to one and a half million. The majority of these are in the 20-49 years age bracket, in other words, the economic backbone of the nation.

The pandemic marches on relentlessly. Why? The reason is that we are reluctant to demystify HIV/AIDS. We, that is the intellectuals of all persuasions, government officials and the public in general. For instance, it is still not a policy for medical personnel to disclose the HIV status of a spouse to his or her partner. And it is only recently that people living with HIV/AIDS have started coming out openly about their status, with all the attendant consequences of stigma, ostracisation, loss of jobs and friends and¾worst of all¾loss of dignity. It is also only recently that people have started speaking out against the tradition of widow inheritance, a retrogressive practice that contributes directly to HIV infection.

Creation of awareness not enough In the fight against the scourge of AIDS two weapons are necessary: (1) awareness of issues related to AIDS and other sexually transmitted diseases (STDs) and (2) change in attitude and behaviour. This is because HIV risk is the product of social, cultural, economic and interpersonal forces that touch us all. It is our behaviour (shaped by our cultures, religious beliefs, social categories, exposure to other cultures and experiences) which put us at risk of HIV infection.

Every other day we read in the media about efforts being made by the government to decrease the rate of spread of HIV infection. These efforts were articulated well during the just concluded conference on HIV/AIDS. The National AIDS and Sexually Transmitted Diseases Control Programme (NASCOP) is mandated to reduce the prevalence and impact of HIV/AIDS through provision of relevant knowledge to Kenyans on HIV/AIDS, mobilization of both fiscal and human resources to handle those infected with HIV, and collaboration with both local and international bodies willing to help address the problem.

Research indicates that most Kenyan's are aware of HIV/AIDS and to a large extent understand the mode of transmission. However, the Kenyan situation is still getting worse and there is a subtle denial of the existence of the pandemic. AIDS is still talked about in hush tones in this country. Nobody ever dies from HIV or AIDS-related illness, but we die from non-stigmatizing conditions through which HIV/AIDS manifests itself and which are acceptable on death certificates.

Creation of awareness, as we well know, does not by itself bring about a change in behaviour. There are various reasons why this is so.

The danger of restricting AIDS to "at risk" groups AIDS is still a condition seen through the epidemiological model based on the premise that the focal point of the problem is a category of "at risk groups." These at risk groups include commercial sex workers, truck-drivers, drug abusers, bar workers and where applicable, homosexuals. The problem with this categorization of at risk individuals is that people in the general population tend to feel safe since they do not fall in the labelled social groups.

The attitude of thinking of AIDS only with respect to at risk groups creates complacency. For example, a married person who has an extra-marital affair with an individual who is not in the labelled category feels safe. This also applies to young people and those who engage in unprotected sexual encounters with under-age persons of both sexes.

The epidemiological model also focuses on the risk behaviour (sex related) of the at risk groups in order to change them through health education and social support. This has been difficult because the sexual behaviour of people is intimately linked to the social milieu in which they find themselves. Behaviour, sex related or otherwise, is a function of many factors, and is shaped by people's internalisation of social expectations or norms in a general value system concerning all aspects of life.

Traditional sexual practices Sexual behaviour¾which is at the core of HIV/AIDS risk¾ is determined by one's cultural and religious beliefs. Many traditional cultures encourage early marriages, polygamy, wife inheritance and subtle promiscuity, especially among men (who are seen to be "polygamous by nature"). No traditional culture, however, categorically accepted promiscuity. What we regard as casual sex was often dictated by other social situations such as the traditional desire to keep families/clans together, migration and prolonged separation of spouses. Most important of all in relation to culture is the fact that traditional cultures saw sex as a means to procreate, and not linked to leisure and recreation. The desire to protect widows, and to ensure that children were not orphaned as a result of the death of their father, was the basis of the tradition of widow inheritance.

Rules and obligations regulating sexual and reproductive behaviour existed in most cultures. Thus traditional culture cannot be the culprit for illicit sexual conduct. Cultural norms specified rules regarding when sexual intercourse should commence: after puberty, initiation and so on; when it was to stop, for example when one's first child got married; abstinence, e.g. during menstruation, pregnancy, post-partum period, etc.

Religion is another dominant force within many value systems. Like culture, it defines beliefs, practices and shapes the ethics manifested in the behaviour of its adherents. Together with secular values decreed by or indirectly relevant to religion, these forces dictate courtship, marriage, mating, conception, delivery and child care. However, these regulations are at best read, too often they are not practiced.

One looks back with nostalgia to the days when sexual behaviour was a community concern, governed by the rules we have mentioned, and even by how people shared dwellings.

Modernisation, migration and poverty: the causes of changing sexual practices The two forces, culture and religion, which regulated sexual behaviour in generally acceptable ways have in this century been bombarded by "civilization" to the extent that at present many variants of religions and cultures exist. The bombardment has come in the form of modernization and changing socio-economic situations. People have moved from protective rural/cultural situations to urbanized, educated, exposed, culturally and religiously heterogeneous situations. This has brought about a new culture, including a change in sexual practices. And it is this new culture which encourages the relentless march of the AIDS pandemic.

It is every man for themselves. Women are left in rural areas while men migrate to urban areas to seek employment. The couples meet probably once a year during the festive seasons. Meanwhile, both or one of the spouse have been "helping" themselves sexually with other partners. The faithful partner may not feel threatened because she/he believes in the spouse. Women especially bear the brunt of these arrangements. They have no negotiation skills for sexual relations nor does culture allow them to refuse their spouses their sexual rights. They cannot even suggest the use of condoms, which offer some protection. Initiating such discussions would be admitting infidelity, a sure way to being divorced or battered. Meanwhile, the virus matches on.

Related to migration is the issue of poverty. Those who migrate to urban areas regardless of their cultural backgrounds find themselves in the lowest strata of society, especially if they have no education. They end up in the slum areas where the circle of poverty, casual sex, unplanned, unwanted children and prostitution abound. Sex becomes a means for earning money and a recreation or coping mechanism.

The children from the slum situation end up on the streets where they are exposed to all manner of vice, including drug abuse, sex and invariably HIV infection. This is because they come from a slum culture of early sex and multiple partners, to which they are exposed at an early age in their make-shift dwellings.

It must not be misconstrued here that psycho-social and cultural aspects in relation to the spread of HIV/AIDS only relate to the un-educated, disadvantaged groups in our community. HIV/AIDS is a problem even amongst the educated and the well to do. Either through denial or pure lack of information, many among these groups refuse to know about AIDS or just wish the problem away. Again because of the labelling of "at risk individuals", some of these educated people feel safe and do not take due care about their sexual encounters, especially if their partners are from their own social groups. They are also better able to deal with their HIV status discretely because most have access to the health system and treatment, while those in the lower strata succumb quicker to the infection and are less able to hide their condition. Also, the advent of the "cocktail drugs" which would be available to those in higher income brackets would make it impossible for one to be identified for as long as a decade before they succumb to AIDS and its overt signs. Meanwhile, they would be infective to unsuspecting sexual partners.

An "I don't care" society Cultural behaviours that are high risk factors for HIV/AIDS infection are well documented. They persist and are fuelled by a fatalistic approach to life that has characterized most Kenyans. Statements like "If I am not killed by AIDS I shall be killed by a matatu or thugs" abound. Even simple knowledge or information on relatively safe methods like the use of condoms is not acted upon. This becomes an excuse to indulge in casual sex without protection, because "nobody enjoys to eat a sweet with its wrapping on." This "so what" attitude has permeated every strata of the society and it will be our undoing. We have become an "I don't care" society. At the highest level of policy making and social guidance we condemn acknowledged methods of control. We thus encourage the "care less" attitude. We hear arguments about whether to offer or not sex/family life education in schools without the debates ever been concluded. Meanwhile Kenyans are dying in hoards.

Religion appears not to be a strong enough motive for checking illicit sexual behaviour Cultural and religious norms which used to regulate sexual behaviour no longer have the same force as in the past and an acknowledgement of this new reality is imperative. It would be ideal if in the a-b-c creed used in counselling ("a" for abstinence, "b" for being faithful to one partner, and "c" for condom use) the "c" could simply be left out. However, while this may be a useful rule for the religiously inclined, others may choose to use such helps rather than change their sexual behaviour.

If condoms, this commodity which provokes such mixed emotions can be one way to help many Kenyans remain free of the dreaded virus, then they should be made available, together with relevant information about their limitations. Human fallibility should not be ignored as there is no agreement about the formation of "authentic sexual values."

The need to target youth and women It may be that the policies in place have missed the point, especially in regard to sex education pertinent to adolescents and young adults. We might not be able to deal with long held habits by adults but we may be able to make a difference by focusing on the youth, by availing to them clear unambiguous information and providing them with services and social support. Policies that empower women on negotiation skills for their bodies need to be put in place. They and young adults should be given the information, tools and power over their lives to allow them to reduce their risk of HIV infection. Policies, cultural practices and attitudes that are repugnant to this right must be denounced and changed.

For the sexually active youth, policies that block access to sexual and contraceptive education and services depict a suicidal society. The youth lack skills to negotiate and manage sexual relationships which result in unwanted pregnancies, babies, HIV/AIDS infection and death.

Conclusion The impact, both social and economic of HIV/AIDS is enormous. A horrifying statistic has recently come to light: that only one out of three poor Africans will reach the age of 40.1 In Kenya, the statistics are that by the year 2000, which is 14 months away, 1.8 million Kenyans will be infected by the HIV virus. Our future is at stake and we cannot continue with business as usual. We must determine what we can do together to reduce that number.

Our complacency must go and should be replaced by an open attitude towards HIV/AIDS and towards prevention strategies. Uganda has shown that it is possible to reverse an almost hopeless situation by acknowledging the problem and facing it openly. This might create a light at the end of the tunnel. We must not give up. It is necessary to keep bringing the issues related to HIV/AIDS into the open.

That the various activities to control the AIDS scourge have not effected change, calls for a more urgent re-evaluation of the strategies being employed to control it, especially the strategies that address behaviour change. Cultural practices (such as widow inheritance, for example) and traditional values that either put people at risk of HIV infection, or directly cause infection have to be addressed continuously and openly. It is an absolute necessity to focus on the dissemination of effective and realistic HIV/AIDS prevention strategies if HIV/AIDS in Kenya is to be demystified.

Notes 1. . Sihm H. "Only one out of three poor Africans will reach the age of 40, so why worry?" J. Lakartidningen, Feb. 12;97 (7): p. 547-8.

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