the mid 1990s it fluctuated around 15 per cent. As in southern Africa, good transport and high levels of mobility ensured an unusually narrow difference between urban and rural prevalences. In 1994 an estimated 41 per cent of all West Africa’s Aids cases were in Côte d’Ivoire.24
Abidjan was not only the place where HIV-1 and HIV-2 met, it was also the epicentre of infection for the entire eastern half of West Africa. This infection spread along two routes. One was the network of migrant sex workers who left their rural homes for a few years to work in the cities of neighbouring countries, seeking to bring home enough to set up a small business or finance their siblings’ schooling, without revealing their occupation to their families or potential future husbands. Like sex workers everywhere in the continent, these women were invariably blamed for expanding the epidemic, although almost all must themselves have contracted the disease from infected men resident in the towns where they came to work. West African sex workers were extraordinarily mobile. Of those attending a clinic in Abidjan in 1992, 82 per cent were from Ghana, 9 per cent from Côte d’Ivoire, and 2 per cent from Nigeria, but by 1998 only 9 per cent were from Ghana, 29 per cent from Côte d’Ivoire, and 56 per cent from Nigeria. Recovery in the Ghanaian economy and recession in Côte d’Ivoire and Nigeria probably shared the explanation with numerous Aids deaths among Ghanaian women and violence towards the Ghanaian community in Abidjan following a soccer match in 1993.25
Ghana was the first country to which Abidjan’s epidemic spread. Testing facilities became available there late in 1985 and were immediately deployed on sex workers. Of those tested in Accra early in 1986, only 5 of 236 were found HIV-positive, but when attention switched to women returning from Abidjan, 74 of 151 were found infected and many already gravely ill. At the end of 1987 the doctor in charge reported that Ghana had 276 known HIV cases, of whom 242 were women, 199 were sex workers returned from Côte d’Ivoire, and 145 came from Ghana’s Eastern Region, where the patrilineal Krobo people allowed women no rights over land and young women had long been engaged in commercial sex. ‘There is no work here,’ a woman from the area explained at that time. ‘In Abidjan I can earn 10,000 CFAs a day. . . . I have about 12 men a day. Since I heard about AIDS I always make them use condoms . . . I don’t know anyone who has it.’26 Although Ghanaians habitually blamed HIV on these women, it was plainly an oversimplification, for they had been singled out for testing and their predominance among those with HIV demonstrated that they had seldom transmitted the virus, which many were probably too sick to do. Transmission was clearly more diffuse. Nevertheless, by 2001, as national adult prevalence hovered around 3 per cent, Eastern Region was still the most heavily infected area and commercial sex was still central to the epidemic. HIV prevalence in Accra at that time was 5.9 per cent among men who bought sex and 0.5 per cent among those who did not. Among men aged 15–19, 84 per cent of cases were attributable to commercial sex.27
This combination of relatively low general prevalence and high infection rates among mobile sex workers and their clients was widespread within the region of West Africa focused around Abidjan. In Benin, for example, HIV prevalence among pregnant women in Cotonou rose slowly from 0.4 per cent in 1990 to 3.4 per cent in 1997–8, while prevalence among the city’s commercial sex workers rose from 3.3 per cent in 1986 to 58.0 per cent in 1997–8. It was calculated in the early 2000s that 76 per cent of male HIV infection in the city was contracted through commercial sex. Benin was unusual in that HIV prevalence in the general population was higher in some provinces than in the capital city, partly because commercial sex, a long-established practice there, was also widely dispersed, with a close correlation between infection in sex workers and in the general public.28 The remarkable point, as in Ghana, was that high infection among commercial sex workers did not precipitate the explosive epidemic seen in Kigali, Nairobi, and Abidjan. One reason was probably the equal gender balance in West African cities other than Abidjan. Another was that condoms had come to be quite widely used in commercial sex: by 54 per cent of clients in Cotonou in 1997–8, so they claimed, and by 90 per cent in Accra in 2001. In Cotonou the age at first sex was relatively high and women in the general population reported few sexual partners. Most important, perhaps, were the two contrasts emphasised by a study in 1997–8 that compared Cotonou and Yaounde in western Africa with Kisumu and Ndola in the east: the high levels of male circumcision in West African cities (almost 100 per cent in Cotonou) and the relatively low levels of HSV-2 in the general population (12 per cent among men and 30 per cent among women in Cotonou).29
Away from the coast, in the savanna hinterland of Côte d’Ivoire, the network of commercial sex remained an important means for the diffusion of HIV, but it was supplemented by a second network of male migrant labour. The effects of migration were especially strong in Burkina, where Aids was often known as ‘the Côte d’Ivoire disease’, ‘a disease of people who move around, who travel and cannot keep still’, as an elder put it.30 ‘From Spring 1990 to Christmas 1992,’ an anthropologist wrote of his village, ‘a score of young-old migrants returned from Côte d’Ivoire, dreadfully bent, with their sticks, without bicycles or suitcases. They had simply come to die in Kampti and its environs.’31 At first the national hospital in Ouagadougou admitted seven male cases for every female, but by October 1987 HIV prevalence among pregnant women in the city was 7.5 per cent and it appears to have hovered around that figure during the 1990s, although rising to 57 per cent among sex workers in 1994.32
Further north, in Niger and Mali, these patterns were repeated but at lower levels of disease and with larger proportions of locally born sex workers. In Niger, for example, 62 per cent of the first 40 Aids cases diagnosed at Niamey hospital were former migrants to the south; their risk factors were listed as ‘prostitution, contact with prostitutes, blood transfusions and histories of visits to coastal countries’. Nearly three-quarters were men, a balance that shifted during the 1990s as infection spread more broadly, although still at relatively low levels. In 2003 adult prevalence was just over 1 per cent, but with 38 per cent among sex workers in Maradi.33 Prevalence was somewhat higher in Mali, averaging 1.7 per cent in adults aged 15–49, according to a population survey in 2001, but with 30 per cent infection among sex workers and significant concentrations in Bamako and in towns like Sikasso and Mopti on migration routes to the south. Some 63 per cent of sex workers in Mali’s four main towns at that time came from outside the country.34 Low overall prevalence characterised other Sahelian regions like Mauritania and northern Chad, where, as in Sudan, levels of infection were higher in the south.35
The pattern suggests that the savanna region’s Islamic social order may have limited the transmission of disease. In Niger, for example, a population survey in 2002 showed exceptionally low infection among young people, only about 0.3 per cent for men and 0.1 per cent for women. Women in this region married very young – a median age of sixteen in Mali – to men nine or ten years older. Often secluded, only 0.1 per cent of women in Niger reported more than one sexual partner in the last twelve months when surveyed in 1998. Most of the 11 per cent of men who reported paying for sex during that year were unmarried. Moreover, whereas women in West African coastal countries practised postpartum abstinence for 10–19 months, during which their husbands often sought other partners, in Mali and Niger the average was only 4–8 months.36 The data suggest that in this Islamic region non-marital sex was to an unusual degree confined to commercial sex workers and young, unmarried, circumcised men, where it was least likely to spread infection to the general population. The same seems generally to have been true in North Africa, where, except in Sudan, official prevalence figures at age 15–49 were generally 0.1 per cent or less and about 100,000 people were thought to be infected in 2005. Although many of the earliest cases there were introduced from Europe by returning migrants, tourists, or injecting drug users, infection during the 1990s appears to have taken place mainly within indigenous but narrow sexual networks, both heterosexual and homosexual, with expansion into the general population confined by the Islamic marital and social order, although it was under increasing strain.37
The spread of HIV in Nigeria needs to be seen in this context. It was often described as a delayed epidemic, ‘with a potential for rapid increase’, but in fact it fitted logically into broader West African patterns.
