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We stop for petrol at a roadside pump about 200 kilometres from Kinshasa.
A couple of trucks are refuelling. The price has gone up again: petrol costs
as much in Zaire as it does in Britain, but here most people earn about
35 Pounds a month.

This is one of Zaire’s few decent roads, running from the capital down
the narrow corridor between Angola and Congo to Matadi, the port. The towns
along the route have almost certainly been affected by HIV: up to a third
of Zaire’s truck drivers are infected.

In neighbouring countries – Rwanda and Uganda, for example – this situation
is worse. AIDS has created a social crisis in this continent: according
to estimates by the World Health Organization, one in 40 people in central
Africa is HIV-positive. AIDS is now the main cause of death in young adults
in Kinshasa, Kampala, Entebbe, Kigali and the other cities of the region.
And heterosexual intercourse accounts for about 80 per cent of the infection
in Africa. At least 2.5 million women are already infected. By the end of
the decade, there will be 10 million children around the world who have
been orphaned by AIDS. A further 10 million children will have been infected
by their mothers in pregnancy and around birth. Most of these children will
be in sub-Saharan Africa. The WHO, which has designated 1 December as World
AIDS Day, predicts that the population of some African countries will actually
decline because of the virus.

With half of the world’s HIV-positive people, Africa urgently needs
to do its own research on the virus, on the epidemiology of AIDS and on
treatments for the disease. But the science of AIDS may seem irrelevant
to countries that lack an infrastructure to make use of it. Without clean
water, hospitals, schools, telecommunications, roads and currency, there
is little hope of applying new knowledge. While Western scientists are developing
increasingly complex strategies against HIV, Africa is still short of soap.

Some scientists fear that much of Western science will be useless to
Africans unless money and expertise is invested in Africa. For example,
there is the search for a vaccine. HIV-1 is more variable genetically than
other human viruses, and some of the strains found so far in Africa are
very different from the classical strain isolated by Robert Gallo and Luc
Montagnier. The differences may be so great that genetically engineered
vaccines aimed at the classical strain may fail to protect against African
strains (This Week, 20 October).

Yet comparatively little effort has gone into analysing the pattern
of strains in Africa. And virtually none of the vaccine researchers have
focused on African strains. ‘The groups that are working on (a vaccine)
are not interested in developing one for the Third World,’ says Peter Piot,
from the Institute of Tropical Medicine in Antwerp. Privately, some scientists
doubt whether pharmaceuticals companies will be prepared to invest in vaccines
intended for use outside the profitable Western markets. But Wayne Koff,
head of vaccines research at the National Institutes of Health in the US,
rejects these fears. ‘If we develop a vaccine that works in only one country,
we will have failed,’ he says.

In order to know more about the variability of strains in Africa, virologists
must work on the spot, says Alash’le Abimiku, from the University of Jos
in Nigeria. Abimiku is currently working at the National Institutes of Health,
trying to sequence various different strains of HIV isolated in Nigeria.
She would prefer to see units set up in Nigeria itself. In collaboration
with Western scientists, she says, local scientists should be trained and
equipped to do the work themselves. ‘At the moment all the sera are taken
out to analyse.’

Even if suitable vaccines are developed, someone will have to pay for
them. Nzilambi Nzila, deputy director of Projet SIDA in Kinshasa, and Bila
Kapita, chair of the ethics committee and based at Mama Yemo Hospital, Kinshasa,
have recently discussed the ethics of future trials of a vaccine in Zaire
with scientists from the National Institutes of Health. ‘We know that after
a trial, we would have the problem of cost in the future,’ says Nzila. During
a trial, the vaccine would be supplied free, but afterwards the recipients
would have to pay.

The same problem applies to drugs – in particular, to zidovudine, formerly
known as AZT and still the only licensed drug for AIDS. ‘We need to know
whether we can have the same results for (zidovudine) in the US, Europe
and Africa,’ says Nzila. But any trials would have to monitored properly,
he says and at present there is no suitable infrastructure. Nor is there
the manpower: ‘If we want to do these trials, we have to motivate physicians
and nurses; it can take up a lot of their time,’ says Nzila.

A visit to Mama Yemo, where most of Kinshasa’s AIDS patients receive
treatment, makes this point clear. There are no sinks or running water on
the main wards. I saw one drip stand on a 70-bed ward. ‘I have soap in my
office, but I buy it myself,’ says Kapita. ‘When I treat patients, I do
so with bare hands; we don’t have gloves except in the theatres.’

The careful reuse of gloves, needles and syringes – all appropriately
cleaned of course – is routine in Africa. At last month’s Fifth International
Conference on AIDS in Africa, held in Kinshasa, several research papers
were devoted entirely to issues such as which types of disposable glove
cope best with repeated use. With such basic problems wasting the energy
of health workers, what hope is there of properly monitored clinical trials?

Jonathan Mann, former director of the WHO’s Global Programme on AIDS
and now at Harvard University, has argued that the West must recognise the
need for affordable drugs and vaccines now. If a vaccine is developed and
the Third World cannot afford it, then AIDS could, at worst, become just
another disease of the southern hemisphere, ignored by the West because
it no longer kills in the West.

The experience of a vaccine for hepatitis B, a virus that causes disease
and may lead to liver cancer, should serve as a warning, says Mann. This
effective vaccine has been licensed for a decade but many developing countries
where infection is widespread cannot afford to use it. ‘Today, a decade
after vaccine became available in theory, it remains unavailable for most
of the world’s population in need,’ says Mann.

Mann has recently proposed a system that would enable pharmaceuticals
companies to transfer the patent on any AIDS drug or vaccine they develop
to an international consortium, while continuing to make a profit. In return
for the surrendered patent, the developer would earn the right to prolong
an existing patent on a profitable drug sold in the West, such as an ulcer
drug. Meanwhile, the consortium would sell the vaccine at production cost
to developing countries (This Week, 15 September). So far, there has been
little response from the pharmaceuticals companies.

Where as vaccines and drugs may be problems of the immediate future,
there is an even more basic need in the present. This is data. Epidemiologists
still have only the sketchiest picture of infection levels, particularly
outside the cities. Without a better assessment of who is infected, it is
difficult for health workers to intervene and target their education campaigns
effectively.

In Zaire, for example, there are virtually no figures for HIV infection
or even for AIDS cases outside the capital, according to Kapita. The AIDS
research agency in Kinshasa, Projet SIDA, has data on three large study
populations in the city, but not on the city as a whole. Projet SIDA has
studied workers at a textile factory and a major bank in Kinshasa. The data
suggest that the prevalence of HIV infection in the population has not changed,
from a level of about 6 per cent, over three years. This is surprising,
given infection levels of around 30 per cent in neighbouring Rwanda and
Uganda.

James Chin, a leading epidemiologist at the WHO in Geneva, says the
study population needs a detailed breakdown by age, gender and other factors
before firm conclusions can be drawn. And he stresses that we have yet to
learn a great deal about variations in sexual behaviour from one country
to another and within one country. ‘We just don’t have the data,’ says Chin.

What are the reasons for the lack of information about infection levels?
Again, an important part of the answer is money. A quick straightforward
antibody test for HIV has existed for several years but screening programmes
in Africa are, at best, patchy. The test costs about $4 plus delivery costs
and import duty.

Claire Mulanga Kabeya, a laboratory technician for Projet SIDA, and
her colleagues, have begun to test people for HIV in the villages of the
interior. The team travels by truck and by plane, with their equipment in
a cool box. The cost of the test kits, needles, pipettes and so on is being
met by two aid agencies – Family Health International in the US and Sanrur,
a Zairean charity. But the grants for these screening programmes last three
months, after which the primary health centres in the villages are supposed
to support themselves. ‘I don’t think it’s possible,’ says Kabeya.

Much of the testing equipment in the city hospitals is provided free
as part of Western research grants. But grants come to an end. Rahma Tozin,
an obstetrician at the University Hospital in Kinshasa, is concerned that
Western researchers, particularly Americans, come into Africa for brief
research forays, only to leave again for a promotion within a few years.
When they go, they take their grants – and their expertise – with them,
she says. ‘When these people go away we don’t know what is going on.’ If
local researchers are to tackle AIDS effectively, they must have equipment,
training – and autonomy, says Tozin. ‘They should let us be responsible
for what we are doing. You provide us with the equipment, we will do the
work ourselves,’ she says.

In the absence of science, there is only prevention. ‘We all know that
condoms protect, but we still do not know the best way to promote and teach
about their use to those at highest risk,’ admitted Michael Merson, the
director of the WHO’s Global Programme on AIDS, in a speech to the Kinshasa
conference. AIDS prevention programmes are tackling the difficult factors
that influence knowledge and sexual behaviour. Here, African women are taking
the initiative.

The WHO has decided to make women the focus of this year’s World AIDS
Day, in recognition of the pivotal role they play in health issues. But
the artificial notion of a ‘day for women’ seems only to emphasise how little
attention African women have received until now in the AIDS pandemic, and
how much their particular problems are rooted in poverty.

Not only are women more vulnerable than men to infection through sex;
in developing countries, they also have to care for sick relatives, even
when they are ill themselves. In much of Africa, women are also the principal
earners for the family, for example selling produce in the markets. And
if there is a problem, it’s likely to be the woman’s fault.

One prostitute explained to us, through an interpreter, that she was
HIV positive but that her boyfriend did not know. He wanted to have a baby
with her and marry her, so he could not understand why she insisted on using
condoms. She did not know what she was going to do next. Perhaps, said the
interpreter gently at this point, we could talk about something else for
a bit.

The woman had become a prostitute after leaving her first husband, a
man who gave her no money and had a string of girlfriends. ‘Proper’ jobs
are often available only on payment of a bribe to the prospective employer.
Children’s shoes cost more than a month’s average salary.

There is nothing unique to Africa about the problems of persuading men
to wear condoms. But, according to Tozin, those problems are intensified
in African cultures by the pressures on women to have lots of children.
Everyone wants to be protected from HIV, but hardly anyone wants to be protected
from pregnancy.

‘The woman is always afraid that if she is not having a baby, the husband
is going to have that baby outside. The baby is a very important element
in married life in Africa,’ says Tozin. ‘And even if the husband understands,
the family around doesn’t’

Most people believe that condoms are appropriate for casual sex, but
reject them in steady partnerships. Proget SIDA estimates that only 3 or
4 per cent of married couples in Kinshasa use them. ‘Men accept condoms,
not with their wives, but when they go out with girlfriends,’ says Tozin.
And if the wife objects, she hasn’t much option. ‘We are talking about women
who are not economically independent,’ says Tozin., According to Kabeya,
‘there is no way, culturally, that a married woman can ask her husband to
use a condom’.

Even where a couple knows that one of them is infected, it will always
be the woman’s problem, says Tozin. ‘If it is the man who is positive, it’s
easier. But if the woman is positive and the man negative, then the husband
instead of using the condom would prefer the divorce.’

Nevertheless, there is some progress, according to Nzila. He has been
instrumental in setting up a clinic at an unobtrusive, downtown location,
where prostitutes can come for treatment for other sexually transmitted
disease, free supplies of condoms, testing and counselling.

Condom sales in Kinshasa have risen, according to Family Health International,
from 300,000 three years ago to about 10 million this year. In Matonge,
the red-light district where some of the best bands in Africa play, Nzila
and his colleagues have enough condoms stocked up in the clinics to float
the Titanic. And, says Kabeya, ‘in the nightclubs they have these big boxes
of condoms and people use them, they do’.

Prostitutes are gradually increasing their use of the free supplies,
according to a study of 1300 women in Kinshasa. In 1988, only 9 per cent
of the whole group ever used condoms – and the percentage using them regularly
was lower.

The researchers followed up a subgroup of 200 women for a year, during
which there were several education sessions and free supplies of condoms.
At the end, this subgroup had 40 per cent who said they always used a condom,
19 per cent who said they did so regularly and 4 per cent who claimed occasional
use. Again, however, less than 10 per cent used condoms with a steady partner.
Mostly, women who failed to use a condom had done so because their clients
had refused and they needed the money.

‘You have to see the effort we are making, to do something for ourselves,’
says Nzila. One study, which the clinic is due to start in the New year,
is a trial of spermicides. Marie Laga from the Institute of Tropical Medicine
in Antwerp is working with Nzila on this project. In the laboratory, spermicides
such as nonoxynol-9 and menfegol appear to prevent HIV from replicating.
If spermicides have this action in the body as well, they may offer an important
advantage over the condom: the woman has complete control of them.

No one knows at this stage whether spermicides could work in this way,
and no one is suggesting using spermicides instead of condoms. The first
step of the trial will be to establish whether it is safe for women to use
these products frequently – a prostitute might need to insert five or more
spermicidal tablets a day into the vagina. One study in Nairobi indicated
that spermicides might in fact irritate the vagina, causing minor ulceration.
This could actually increase the risk of infection. But Laga says the study
was not conclusive. The WHO has agreed to fund the Kinshasa trial.

Women who participate in the trial of spermicide safety will be monitored
carefully for any signs of ulceration. They will continue to use condoms
as well as the spermicide. If there are no harmful effects, a second trial
may take place to see whether spermicides reduce the risk of infection in
women. Again, condom use will be encouraged. While the spermicide is not
intended as an alternative, says Laga, researchers need to be realistic:
‘Everyone knows that people do not use condoms all the time.’

Talking sex with children

All this is fire-fighting, however, compared to the work of the Society
for Women and AIDS in Africa. SWAA was set up in 1988 by a group of African
women that includes Kabeya. The aim was to try and focus AIDS prevention
efforts towards the particular needs of women.

Kabeya is also president of SWAA Zaire. This group is focusing its attentions
on schoolchildren as young as 10 years. According to this group, a significant
minority of children in the city are starting intercourse between the ages
of 11 and 15 for reasons based on ignorance. Kabeya says some boys fear
they will become impotent without sex, and some girls think they will become
infertile.

Another study, by Eka Gwan from Yaounde, Cameroon, found that sex education
in schools in Yaounde was often wide of the mark. ‘Pregnant teenagers were
taught what is now useless to them and what they think useful was never
taught,’ the researchers said. They concluded that parents and teachers
may need to be educated before the children. In an attempt to rectify matters,
SWAA is going into schools every week to talk with children about sex. ‘I
think we are doing a really good job; they are asking a lot of questions,’
says Kabeya.

Refiloe Serote, who works for the Township AIDS Project in Soweto, South
Africa, says mothers must discuss sexuality with their children. Only then
will children get a reliable sex education. While sex remains a taboo subject,
women will continue to take the blame for everything, she says.

‘If a man has got a sexually transmitted disease he will always say
he got it from a woman,’ says Serote. ‘Educating women is the answer to
all these things, so that when a person is blaming you you can explain to
him, but without that knowledge you won’t be able to explain to him or protect
yourself, to argue against what he is saying. It is our responsibility as
women to teach them and to make our partners aware. We just have to be clear
and fight for our rights.’

* * *

How likely is the virus to spread from mother to child?

Africa currently has five-sixths of the world’s HIV-positive women.
So it is here that studies are most needed to find out why some women infect
their offspring and others do not.

A large study in Europe suggests that only one in five or six HIV-positive
women will infect her child (This Week, 13 October). But in most African
studies, a higher figure has emerged – about one woman in three. For example,
a study by Rwandan and French researchers from the Central Hospital, Kigali,
and the University of Bordeaux, has found a transmission rate of 33 per
cent.

There are several theories to explain the differences. It could be that
some of the African strains of HIV are more virulant. Another theory is
that the virus may replicate more rapidly in people whose immune systems
are constantly stimulated by parasites and endemic infections in Africa.

So far, the indivudal factors that increase or decrease risk are unclear,
according to Marie-Louise Newell, coordinator of the European study at the
Institute of Child Health in London. It seems more likley that infection
takes place in the womb than at the time of birth, she says. It makes no
difference to the risk whether a baby is born vaginally or by Caesarean
section.

So far, there is no evidence that the stage of the mother’s disease
at the time of birth affects risk. However, researchers would expect the
amount of virus in the body to be greater when a women has AIDS than when
she is free of symptoms; this might increase the risk of transmission. But
too few women with AIDS have been studied for firm conclusions to be made.

Pratibha Datta and her colleagues at the University of Nairobi have
enrolled about 80 children of HIV-positive mothers so far in a long-term
study. Their initial data suggest that women who became sexually active
relatively soon before their child was conceived were more likely to transmit
the virus than women who had been sexually active for many years when they
became pregnant. The most likely explanation, says Datta, is that a woman
who has recently begun to have sex has also recently become infected. Shortly
after infection, HIV levels in the bloodstream rise temporarily before falling
to low levels.

Meanwhile in Marseilles at a retroviral research unit of INSERM, the
French medical research council, Jean-Claude Chermann and his colleagues
have begun a study of placentas from HIV-positive women to try to establish
exactly how infection of the fetus takes place. One theory, says Chermann,
is that infected macrophages from the mother may cross the placenta.