of this epidemic suggests a combination of circumstances fostering disease elsewhere but seldom joined in one place. One was participation in lakeshore fishing culture. ‘The beaches attract a continual inflow of people,’ it was reported: ‘young men in pursuit of an easy cash income and women following the men. They live outside the traditional social structure and subsistence farming households, and drinking, casual sex, theft, HIV/AIDS and high death rates among young men are common.’ Nearly half the adults in these areas may have been infected by the early 2000s.54 Equally vulnerable were young people with casual jobs on sugar plantations and especially on the fringes of the transport industry, for Nyanza straddled the trans-African highway and had its own motor transport network. Its dense rural population, closely linked to the urban focus of infection in Kisumu, bred rural prevalence levels among adults reaching 30 or 40 per cent in the early 2000s, while scarcity of land and lack of rural opportunity perpetuated migration to Kampala, Nairobi, and workplaces throughout Kenya, where Nyanza people often had exceptionally high rates of HIV.55
The social organisation of the Luo people also contributed to the epidemic. One study attributed over half their infection to the fact that some 90 per cent of Luo men, unlike most Kenyans, were not circumcised.56 Their society was strongly patriarchal. In interviews at clinics in Kisumu in 2000, with Luo forming 81 per cent of those questioned, men reported unprotected sex with an average of 11.2 partners, women with 2.5. It is not clear whether these women included sex workers, but they numbered an estimated 1,400 in Kisumu in 1997–8 and 75 per cent of them were HIV-positive.57 Many were probably divorced or separated women with few other opportunities in Luo society. Luo themselves saw the epidemic as only the culmination of a century of economic decline and social disintegration, focusing particular attention on their custom of inheriting widows (and hence, supposedly, the virus that killed their husbands) and on alleged youthful promiscuity. One study in the rural Asembo area in 2004 showed that 33 per cent of boys and 22 per cent of girls under fourteen years of age claimed sexual experience, which had probably been common among youths in the past but had taken non-penetrative forms. A survey of women in Kisumu in the late 1990s found HIV infection only among those who had engaged in premarital sex.58 Female prevalence there rose from 8 per cent at age 15 to 29 per cent at age 17, at which age only 2 per cent of men were infected. Of every five people with HIV, three were women.59 The connection between gender inequality, sexual behaviour, and vulnerability could scarcely have been stronger.
Except, perhaps, in Ethiopia. In its origins the Ethiopian epidemic differed from those elsewhere in eastern Africa, but in most other respects it was, despite the country’s distinctive history, surprisingly similar, especially in the unsuspected early spread of heterosexual infection arising from sexual exploitation of women. The problem in Ethiopia, however, is not, as in Nyanza, why an extensive epidemic took place, but rather, as in pre-genocide Rwanda, why the epidemic was not more extensive. This may seem paradoxical, for in the early 2000s about 1,500,000 Ethiopians had HIV. Yet that implied a prevalence in those aged 15–49 of 4.4 per cent, only half the proportion in Tanzania and two-thirds of that in Kenya.60
One reason restricting the epidemic was that HIV reached Ethiopia somewhat later than the other eastern African countries. The first two cases were diagnosed in Addis Ababa in 1986. Retrospective tests on stored blood revealed one case in 1984 and another in 1985, but none in earlier specimens. Analysis of the diversification of the virus suggested that it had arrived in 1983. The virus itself, introduced at least twice, was subtype C of HIV-1, in contrast to the A and D subtypes dominant in East Africa. How the subtype mainly found in southern Africa and India also reached Ethiopia is unknown, but its complete domination of the epidemic – in contrast to the diversity of subtypes in Tanzania – suggests not only Ethiopia’s isolation but a rapid saturation of a core group of vulnerable people from whom the infection spread to the wider population.61
The core group were the sex workers of Addis Ababa and other major towns, together with their habitual clients. Founded in 1886 on the model of a military camp, the capital was a sprawling jumble of permanent buildings and the squatter shacks in which over four-fifths of its nearly two million people lived. Women were a majority of the population, especially in the younger age ranges, for Ethiopian women married very young, divorce was common, and there was little place for unmarried women in the countryside. In the town, such women survived chiefly by informal activities, of which commercial sex was one of the most important. In 1973–4 an Ethiopian sociologist reckoned that some 27,000 women worked in bars, the chief meeting places for the city’s men. An official survey in 1982 identified 15,900 full-time sex workers in the city. A less official one, seven years later, estimated 24,825, excluding streetwalkers and women working from their own rooms, adding that 55 per cent had only one or fewer partners per week.62 Divorce, disagreement with parents, and lack of money to continue schooling were reasons often given for entering commercial sex. Major provincial towns had smaller but similar groups of sex workers.
Commercial sex had a role in Ethiopian urban culture similar to that in Kigali. Female virginity at marriage was vital to respectable families, if perhaps less so to their daughters than in the past, partly because marriage ages were rising with education. Men, by contrast, suffered little inhibition on sexual experimentation and on average (in 2000) married seven years later than their wives. Given this imbalance, as in Kigali, young men commonly had their first experience with sex workers and up to half continued to frequent them thereafter. Early in the epidemic most of these sexual encounters were unprotected, for Ethiopians were unfamiliar with condoms and hostile to them.63 Sexually transmitted diseases liable to facilitate HIV transmission were common, especially among sex workers. A study in Addis Ababa in the early 1990s found that only 9 per cent of women in their first marriage and 1 per cent of sex workers had no serological evidence of such a disease, while 33 per cent and 46 per cent, respectively, were infected with HSV-2, which caused genital ulcers and particular susceptibility to HIV. Moreover, Ethiopia’s health services were slender even by African standards, taking only 0.4 per cent of the national budget in 1999 and providing fewer than 20 per cent of pregnant women with antenatal care, as against an average of over 60 per cent in sub-Saharan Africa.64
HIV first became established in Addis Ababa among sex workers during an explosive epidemic in the late 1980s. In 1987, 5.9 per cent of them tested positive; by 1990 the figure had risen to 54.2 per cent. Prevalence was especially high in city centre brothels. By contrast, in 1989 only 4.6 per cent of the capital’s pregnant women were infected.65 Other places of very high prevalence among sex workers at this date were the trucking towns of Dessie, Nazareth, Mekele, Bahr-Dar, and Gonder on roads radiating outwards from Addis Ababa. In the far north, however, the disease was still rare, although it had penetrated to all parts of the country. Study of 23 towns in 1988 showed an average prevalence of 17 per cent among sex workers, 13 per cent among long-distance truck drivers, but only 3.7 per cent among blood donors (who broadly represented the general population).66 Among the latter, rapid epidemic growth began three or four years later than among sex workers, the annual incidence of new urban infections peaking in 1991 at about 2.7 per cent. Prevalence among antenatal women in Addis Ababa rose from 4.6 per cent in 1989 to 11.2 per cent in 1992–3, reaching its likely peak of 21.2 per cent in 1995.67
At the same time, the ratio of infected men to infected women in the capital fell from 3.7:1 in 1988 to 1.5:1 in 1994, suggesting that an epidemic that had begun among a core group had spread to the general population. In a study of 2,526 factory and estate workers in and around Addis Ababa in 1994, HIV infection in men was strongly associated with reported sexual behaviour and past history of syphilis, but in women it was associated with sociodemographic characteristics (low income, low education, and living alone) rather than sexual behaviour. Moreover, the burden fell increasingly on young women. In 1995, antenatal prevalence in Addis Ababa was 23.7 per cent among women aged 15–24, 17.7 per cent among those of 25–34, and 11.1 per cent among older women. In Dire Dawa, a railway town east of the capital, 57 per cent of all infected women in 1999 were aged 15–24.68
Ethiopia’s urban epidemic ceased to expand during the mid 1990s, although numerous new
