of about 1.9 per cent among pregnant women. During the next six years it rose gradually to 5.4 per cent and the variation between different states widened, but those most affected were scattered broadly across the country. The highest prevalence (16.7 per cent in 1999) emerged in Benue state, in central Nigeria, where Aids was known as ‘the Abuja disease’. ‘No one suffers from this sickness in our village here,’ it was said, ‘but these women who go to Abuja [for commercial sex] suffer from it. They come home almost dead.’ Of 40 people with Aids studied in that village, only one did not have a history of ‘life abroad’. The next highest prevalence was 12.5 per cent in Akwa-Ibom state in the extreme south-east, where cross-border traffic coincided with great female independence and exceptionally high levels of commercial sex.39
Three reasons may help to explain why Nigeria did not suffer an explosive epidemic like that in Côte d’Ivoire. One was that Nigeria was too big and diverse, with many local epidemics but no primate city to transmit disease throughout the country. Rural prevalence was higher than urban in some states in the early 2000s. The second reason was that sex workers were mostly Nigerians and only marginally involved in the wider West African sex trade, at least until the later 1990s, so that even in 1994 only 13 per cent of sex workers in Lagos were infected. The third reason was the restraint imposed by the culture of the Muslim north, where women were commonly secluded and average HIV prevalence was significantly lower than in the centre and south-east.40 It is more difficult to explain why prevalence was even lower in the south-west, where extra-marital sex had long been common among the Yoruba and had become increasingly so among the young in the course of the twentieth century, unless perhaps the very diffuseness of partnerships rather than their concentration around high-risk sex workers gave protection.41 On the other hand, one factor encouraging the spread of disease was the mediocrity of Nigeria’s health system, rated by the World Health Organisation as one of the worst in the world. In 1995 the Federal Ministry of Health estimated that 10 per cent of HIV transmission was by blood transfusion, a problem still unresolved ten years later.42
In 1995, also, Nigeria’s health authorities estimated that at least 24 per cent of the country’s HIV infections were by HIV-2, although the country lay well outside the range of the sooty mangabey.43 The virus had probably entered Nigeria from the west at much the same time as HIV-1 was spreading from the east and south. Further west along the Guinea coast and in Senegambia, however, HIV-1 had to penetrate a region where HIV-2 was already endemic, if generally at low prevalence. The first search for HIV-1 in Senegal in 1985–6 chiefly revealed cases of HIV-2, both among sex workers in Dakar and especially in the southern Casamance region bordering the epicentre of the disease in Guinea-Bissau. Almost all were Senegalese who had never left the country, whereas the first HIV-1 cases identified were predominantly foreigners or Senegalese men who had travelled elsewhere in West or Equatorial Africa and often had histories of homosexuality or drug use. In 1990 Senegal’s national prevalence of HIV-2 was reckoned to be nine times that of HIV-1, but the greater virulence of the latter enabled it to overtake HIV-2 in 1996–7. By 2004 HIV-1 in Senegal was sixteen times more prevalent than HIV-2, which was of equal importance only in the Ziguinchor region on the Guinea-Bissau border.44 During the 1990s this reversal took place everywhere in the western coastal region except Guinea-Bissau, where the differential between the two infections narrowed but did not close, chiefly because of continuing (although declining) high levels of HIV-2 infection among older women.
Senegal gained international renown by limiting its national HIV prevalence at age 15–49 to little more than 1 per cent. Much of its infection was concentrated among the Jola people close to the southern border with Guinea-Bissau, where prevalence was two or three times the national average.45 Young, infected Jola migrants began to return from Côte d’Ivoire during the late 1980s to die at home. Like the Yoruba and many other young people throughout the continent, they had during the twentieth century adopted risky patterns of pre-marital sex in response to the commercialisation of the economy, the need to migrate for urban employment, the declining status of women consequent on the spread of Islam, the increasing difficulty of marriage, the collapse of customary sexual restraints, the spread of sexually transmitted diseases, the marginalisation of the region within independent Senegal, the destructive impact of structural adjustment policies, and their continuing anxiety to bear children at the peak of fertility.46 Elsewhere in Senegal, however, Muslim culture provided greater protection. There the median age of sexual debut was high, at about 19 years for both sexes during the late 1990s, levels of non-marital sex were low outside the capital, and condoms were quite widely used with casual partners. The government’s important part in containing disease will be considered later, but Senegal’s experience, like Nigeria’s, fitted closely into the wider patterns of West Africa, where the great regional variations in HIV prevalence witnessed to an epidemic that had penetrated but not conquered.47
7
Causation: A Synthesis
The HIV-1 epidemic that Kapita Bila had first glimpsed in Kinshasa in the mid-1970s had taken almost exactly ten years to spread and become visible among the African peoples at the three corners of the continent, appearing in Ethiopia, South Africa, and Senegal almost simultaneously in the mid-1980s. Having traced that expansion, it is time to return to President Mbeki’s question: why has Africa had the world’s most terrible HIV/Aids epidemic? An answer must bring together the nature of the virus, the historical sequence of its global expansion, and the circumstances into which it spread, giving particular weight among those circumstances to gender inequalities, sexual behaviour, and impoverishment. Many existing answers perhaps concentrate too exclusively on the circumstances, arguing for the primary importance of either sexual behaviour or poverty.1
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