BOOKS & ELECTRONIC MEDIA

HIV and AIDS in Africa: beyond epidemiology

Shabbar Jaffar

Senior Lecturer, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1 7HT, England (email: shabbar.jaffar@lshtm.ac.uk)

Editors: E. Kalipeni, S. Craddock, J. Oppong, J. Ghosh
Publisher: Blackwell; Oxford, England; 2003
ISBN: 0631223576; 416 pages; £19.99 (softcover)

This is a comprehensive work which focuses on the social and economic forces that have facilitated the spread of the HIV/AIDS epidemic in Africa. The authors of its 23 chapters are largely social and behavioural scientists and economists. Its target readership is the wider public health audience, including policy-makers, epidemiologists and clinicians.

The book is divided into five parts. Part I (two chapters) covers the history of AIDS as well as some of the political and cultural aspects of its spread in Africa. Discussed are the early misconceptions about AIDS, the slow responses by government in most parts of world, and the stigma that came with the disease. References are made to the link between HIV/AIDS, colonial history, including colonial medicine, and traditional cultural practices conducive to the spread of HIV in Africa.

Part II (three chapters) focuses on regional perspectives. It discusses misperceptions about AIDS, homosexuality and AIDS in Africa, urban sexuality, and attempts to box HIV into a simplistic model ignoring the complex social and cultural and economic issues. The discussion is detailed and critical, with some of the criticisms raised being possible only with the hindsight that we now have. In a few places, the opinions of the authors are stated without supporting evidence. For example, there is discussion of the possibility that unsafe medical practices may be far more important than sexual activity in the spread of HIV, a hypothesis that is contradicted by the vast body of evidence and indeed by the discussions in later chapters of the book. Differences in the spread of HIV between various parts of Africa and between rural and urban areas are discussed in a detailed and interesting way, focusing on the social and cultural issues.

Part III, by far the biggest in the book (10 chapters), attempts to grapple with the issues in social terms. Using findings from various research studies and case studies, the chapters discuss gender vulnerabilities, HIV among adolescents, mobility, migrancy, masculine identity and AIDS, homosexuality, and war in relation to the spread of HIV. There is also a chapter on socioeconomic obstacles to HIV prevention and treatment. Epidemiologists may be uncomfortable about the idea of making policy decisions based on the results of some of the small-scale anthropological studies that are described, with subjective outcomes, and would probably be happier with large-scale population-based studies that have biological outcomes. Also, in a few places conclusions are drawn from observational studies in the absence of clear evidence from randomized trials, such as for example the links between circumcision, sexually transmitted infections and the risk of HIV. Nevertheless, this part of the book is, by and large, interesting and informative.

Research methods, agendas and ethics are the focus of Part IV (three chapters). The first two chapters deal with participatory qualitative research and helping Africans to move the HIV/AIDS research agenda forward. The third chapter, on ethics, re-visits the debate on placebo-controlled trials of zidovudine (AZT) regimens in Africa to reduce mother-to-child transmission of HIV. In this context it would have been informative and novel to the see also the views of the African researchers who were investigators on the AZT placebo-controlled trials in Africa. A greater focus on current ethical issues around provision of antiretrovirals would also have been useful.

Part V deals with the repercussions and impacts of HIV/AIDS in Africa. Accounts are given by individuals and families of the impacts of AIDS. There are also informative chapters on AIDS orphans and on the economic impact of HIV/AIDS in Africa. The concluding remarks following the final chapter emphasize the need to gain a better understanding of the spread and effects of AIDS.

Overall, this is a captivating and informative book that is easy to read and can picked up at any time. It has something for everyone interested in the impact of HIV/AIDS in Africa. There are some statements in it that not everyone will agree with; however, the arguments it presents will be interesting and informative to many.