Risk - Taking Behavior and Substance Abuse Vis-a-Vis HIV Transmission in African Societies.

The paper gives a brief synopsis of the prevalence of HIV/AIDS in several African countries. It looks at the general causes of the spread of the epidemic and zeroed in on risk behaviors perpetrated by young adults in African societies. Those discussed include promiscuity, rape, unprotected and often casual, heterosexual relationships, drinking of alcohol and smoking of cigarettes and marijuana. The author points to the fact that intravenous drug usage [IDU] and the use of heroin and cocaine is not common in most African countries sampled, but stresses that there is dire need for research that can investigate the correlation between IDUsers and HIV transmission in African societies. This could begin in any of the relatively `advanced' African countries.

Africa is currently believed in international circles to be the continent with the highest prevalence and transmission of HIV/ AIDS infection. According to a United Nations[UNICEF] report on AIDS released in June 2000, Africa has an estimated 24.5 million people living with AIDS out of the 34.3 million affected by the incurable disease worldwide. 70% of people infected with HIV are from sub-Saharan Africa; with four million new infections in 1999. The estimates added that HIV infects every minute at least six people between the age 15 and 24 years. However, it has been estimated that the countries north of the Sahara record the lowest while the highest records of HIV prevalence not only in Africa but in the world are found in the countries of Southern Africa, East African and then West African countries in that order [Maganu, 2000].

The UN report indicated that Botswana leads with a HIV prevalence rate estimated 35.8% among adults and children in the world.

Table 1 shows the pervasiveness of HIV/AIDS pandemic in some African countries.

Table 1
Prevalence of HIV/AIDS in some African
societies [United Nations Annual Report on
HIV/AIDS, 1999]

Serial   Country          Female   Male   Cumulative
No.

1        Botswana         34       16     35.8
2        Lesotho          26       12     23.57
3        South Africa     25       11     19.94
4        Zimbabwe         25       11     25.06
5        Namibia          20        9.1   19.94
6        Zambia           18        8.2   19.94
7        Malawi           16        7.0   15.96
8        Mozambique       15        6.7   13.22
9        C.African.Rep    14        6.9   13.84
10       Kenya            13        6.4   13.95
11       Ethiopia         12        5.7
12       Burundi          12        5.7   11.32
13       Rwanda           11        5.2   11.21
14       Cote d'Ivoire     9.5      3.8   11.76
15       Tanzania          8.1      4.0    8.39
16       Cameroon          7.8      3.8    7.73
17       Uganda            7.8      3.8    8.3
18       Congo             6.5      3.2    6.43
19       B/Faso            6.5      5.8
20       Togo              5.5      2.3
21       D.R.Congo/Nig.    5.1      2.1    5.06
22       Chad                              2.7
23       Benin Rep                         2.2
24       Swaziland                        25.25

But at the moment, Nigeria's estimated 2.6 million adolescent and adult populations living with HIV has been rated the highest in West Africa and ranked second after Ethiopia in Sub Saharan Africa (Jimoh, 2000). In high-incidence countries, such as Botswana, Swaziland, Lesotho, Zimbabwe, Zambia, Uganda, Tanzania, Malawi and South Africa, the maximum HIV prevalence ever attained by sentinel, ranged from 30.4 to 70.2 percent between 1994 and 1996. (Maganu, 2000). The AIDS toll in high-incidence countries is altering the economic and social fabric of the society. HIV/AIDS will kill more than one third of the young adults of countries where it has its firmest hold. For instance the UNAIDS report for 1999 predicted a pyramid population may be in place in Botswana by 2020. As at now, it seems the global response is still just a fraction of what it could be. We need to respond to this crisis on a massively different scale from what has been done so far.

Risk-behaviors among some members of societies in Africa

Many concerned researchers and epidemiologists have wondered why HIV/AIDS prevalence is as it is. It is tilted towards the sexually active adolescents and youth. Several factors have been identified as contributing to the spread of HIV worldwide. One group of such is risk- behaviors and substance abuse. Examples of these include: HIV needle risk behavior and drug abuse (Carlson et. al. 1999). Young people with alcohol use disorders are at risk for contracting sexually transmitted diseases including HIV (Barley, 1999). So also are those who suffer from depression. Heterosexual risk taking experiences such as engaging in promiscuous unprotected sex, having multiple, sexual partners and often with casual sex partners [Jack et al, 1999] are common. Others are smoking cigarettes and marijuana, excessive drinking of alcohol; Substance abuse such as amphetamine injections; using cocaine, heroin and various types of hallucinogens.

Some of the reasons already identified for the spread of HIV among members of some African societies include the following: denial, prostitution, promiscuity, mobility in population, cultural practices such as circumcision, use of alcohol and marijuana.

Denial is a major driving force of the HIV/AIDS epidemic. People suffering from AIDS claim they have other less stigmaladen diseases such as cancer or TB. Some of those living with AIDS deny it so as to avoid being stigmatized, losing their friends or care of the community members, or to avoid been treated as outcasts. This is common in the rural areas. Prostitution: Frustrating situations often force some young teenagers and ladies, who have to fend for themselves and their families, to have multiple male friends with whom they have sex in return for financial support. In the face of urban poverty, women and even young girls plunge headlong into commercial sex rather than starve to death. They do this with full knowledge of the high risks involved, especially the risk of STDs and HIV/AIDS. According to a spokesperson for sex workers in an East African country, to them it is like a choice between the devil and the deep blue sea. Some people even entertain the view that everyone would die and something would be the cause and that AIDS is just one of the possible causes of death. They would continue to fend for themselves and their dependents through sex work until they can no longer do so. Thus they continue to serve as a veritable source of transmission of HIV/ AIDS.

Increasing mobility in population: This contributes to the spread of HIV from urban to rural areas. Many people now move to and from towns and suburban areas faster and more frequently than before. Factors such as frequent transfer of civil servants resulting in separation of couples; good road networks, shuttling between homesteads and cattle posts and land areas across seasons make people living in Botswana one of the most mobile people in the world. These factors explain the narrow gap [39 to 43%] between the rural and urban HIV infection rates in Botswana [Ministry of Health, Gaborone, 1997]. This population mobility often encourages mixing of people, carelessness or carefree attitude to life such as: pub crawling habits of youth, rough or loose life style. Early introduction to sexual experience through sexual coercion or rape is common in some sub Saharan countries. To some extent, it could be due to lack of information or refusal to behave responsibly on available information on HIV/AIDS/STls (Mwagwa et. al. 1997).

Some cultural practices have been implicated too. For instance, the risk of HIV infection is estimated to be 2 to 8 times greater for uncircumcised men than uncircumcised men [Bloemenkamp et al, 2000]. Usually children especially male are circumcised as soon as they are born. But in some cultures, circumcision is postponed until they reach adolescence or puberty. This is done in what is called initiation ceremony. What is common with the practice is that the same implements are used for all the children at any given occasion. One may not be sure of how sterile the implements are or who is HIV positive among the initiates. There is anecdotal information that HIV could be transmitted via the blood of infected persons among them. Some peer groups tend to enforce conformity and unity among members by making tattoos on their bodies with knives, which might not be very sterile and could be sources of transmission of HIV/AIDS infection.

Out of the estimated figures in various African countries, the adolescents and young adults below the age of 25 years have been found to be peculiarly most sexually active. They have been implicated as being the most responsible for transmission and infection. These young people want to experiment with many things including unprotected sex. The males engage more in risky behaviors than females (Uwakwe, 1998). Examples of such risky behaviors include early, at times, unbridled and often continuous but unprotected sex before marriage and even during marriage. This they engage in with single but usually multiple and quite often casual heterosexual partners.

Socialization: The African male child has been identified as being responsible for his risky behavior. Individuals from high socio-economic homes tend to be more involved in risky behaviors than the poor ones (Uwakwe 1998). Most risk takers are found in all spheres of life, especially in the secondary and tertiary level institutions across the continent. Risk taking behavior has been reported to increase from early adolescence up to early adulthood. Religion has been mooted as a factor that helps check the spread of HIV. For instance, the Roman Catholic Church preaches abstinence and some of its adherents heed. The people living in Moslem dominated countries in Africa seem to have a low incidence of HIV.

Rape: Rape is a very serious pedophilic disorder and offence. It is ravaging some African countries, especially in southern Africa. In a particular one, a TV advert claims that a woman is raped at the rate of every six minutes somewhere in the country. In 1993, in another country, on average, two cases of rape were reported a day, country wide [Soloba 1995]. Some of the rapists were reported to be young adults and teenagers who knew they were HIV positive, others were either complete strangers of people known to the rape victims. Some of those apprehended for such an offence claim they do so because some females passed it to them and therefore they would pass it on to any other woman who they come across. Some of those who commit rape often have as their targets young or prepubertal girls, as they believed such acts could cure their AIDS problem in some instances, their victims could be very old women whom they could overpower.

The Use of Marijuana: Many people start smoking cigarettes as early as when they are adolescents and go on to smoke more at adulthood stage. Some even graduate into smoking marijuana. Marijuana has been found to make its users become intoxicated, disoriented, experience the feelings of euphoria, relaxation and release inhibitions. Some users claim that its use can act as depressant but at high levels, the drug may induce marked sensory distortions of vision, hearing or body balance. All these predispose of male and female users to indulge in heterosexual intercourse with people who could be HIV positive and could transmit HIV/AIDS to others.

Users are often found as members of various adult groups, as gangs or even friends: Many of the users tend to live in disadvantaged areas: It is in such places they engage in voluntary and forcible heterosexual escapades. However, it has been found that the pattern of usage differs markedly from that in industrialized countries, where much higher rates of cannabis dependence as well as use of intravenous injections, heroin, and cocaine have commonly been reported. (Adesanya et. al. 1997).

Use of Intravenous Drugs in Africa

The first generation of AIDS was among the intravenous drug users (Redfield, 1987). According to Cochran and Mays (1989), the risk of HIV infection for any individual depends not only on the occurrence of risk behavior. It depends also on the performance of it in an environment where HIV is present. For instance, nearness to the source of drugs or where intravenous drugs are used or where sharing of the paraphernalia of drugs is practiced could be very influential in this risky behavior. These conditions are not popular in Africa as at now. Many researchers had conducted studies on various forms of transmission of HIV/AIDS and in the area of substance use or abuse. It however, seems that in most African countries, very little research work (if any at all) has been done in the area of epidemiology of HIV/AIDS in young adults who are IDUs. To many individuals interviewed on this population of transmitters, it sounds very alien and even very unAfrican. There are no serious signs that IDUs form a significant percentage of those responsible for the spread of HIV/AIDS in Africa especially when compared with the reports in literature on subjects in USA and Europe. The use of Intravenous Drugs in Africa must be in its rudimentary stage - wherever it may exist, probably, it might be found among the most sophisticated or elitist substance users in the continent. More research efforts will bring out the truth on this.

Sharing of needles and syringes is an important method of transmission of HIV/ AIDS especially among youth in USA. A tiny amount of blood left in needles or syringes just used by someone who is HIV positive can be passed on via injection directly into the blood stream of someone else - which is thus infected. Simpson (1998) found that the diffusion of drug injecting has been particularly pronounced in drug producing and transport countries in South East Asia, especially in the subregion that embraces Thailand and Yunam (China) and Manipur (India). Carlson et. al. (1999) found that IDUs who smoked crack less than daily were more likely to have injected with needles and syringes used by the others especially those in their groups. This practice has not been reported in Africa

Substances commonly injected include amphetamines, cocaine and heroine. Those often implicated are friendly male and female sex partners. The factors that instigate IDUs are availability of such drugs and deferment to expertise in injections or the need for experimentation in many young adult users. Very little is known about drug injection among African subjects.

Next steps in addressing HIV/AIDS and substance abuse in developing [African] countries should include the following suggestions.

1. Mobilize all sectors of each country - such as education, health, economy, security into non-deception action aimed at presenting a united front in the battle against AIDS.

2. Remove poverty situations; and promiscuity will reduce.

3. Give adequate socio-personal counselling.

4. Discourage the use of psychoactive substances.

5. Let more government, nongovernmental and cultural organizations be actively involved in the campaign against the use of substances.

6. Use phone-in programs on radio and television to reach more people.

7. Let there be increased awareness, health, education, human and financial support and full scale participation by all sectors to Stem the tide of the pandemic in the various countries.

8. Let everyone, young and old, know about HIV/AIDS, preventive measures and its implication on human development.

9. Use billboards with neon lights to fight its spread in places such as nightclubs.

10. Make advertisements discouraging the spread of AIDS in the print media such as newspapers and magazines.

11. Use mass public educational strategies, on streets and in public modes of transportation.

12. Use the local languages, especially in the rural areas. Always use the level and type of language the youth speak and understand.

13. Make use of video, drama and films.

14. Give well planned health education that is culturally relevant.

15. Develop programs to facilitate positive development of the young adults.

16. Operate holistic approach - one that involves everyone in the family or community.

17. Ban films that show IDU except those that highlight its negative effects.

18. Discourage them from obtaining substances and other drugs.

19. There must be a rethink by all stakeholders and signs of political reawakening to curb the spread of IDUs (wherever they exist) must be seen.

20. Individuals must be helped to translate knowledge to practice.

All those who inject any form of drug must use disposable needles and syringes; otherwise, they would share these with any other person.

In conclusion, it could be stated that young adults in Africa engage in some risk-behaviors. The most common ones are alcoholism, smoking of cigarettes and marijuana and promiscuity. However, the use of Intravenous Drug Injection (IDI) is not a familiar example within very many traditional African societies. But this author does not over rule out its existence in highly sophisticated environments. The implication of this is that there should be further research to find out the relationship between IDU and transmission of HIV/AIDS. This article has listed some examples of steps to address HIV/ AIDS and substance abuse in developing countries.

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E.A.Akinade, Ph.D., Faculty of Social Sciences, University of Botswana, Gaborone.

Correspondence concerning this article should be addressed to Dr. E. A. Akinade, Faculty of Social Sciences, University of Botswana, P/Bag 00705, Gaborone, Botswana e-mail: [e-mail]