Why is HIV/AIDS so bad in Southern Africa?

AIDS is bad throughout sub-Saharan Africa, but it's much worse in Southern Africa, particularly in Botswana, South Africa, and Swaziland. I've been trying to figure out why this is. It's a challenging question. I've been doing a bit of research and it seems there isn't a single reason (or set of reasons) that everyone agrees upon. Dr. Kevin De Cock (no, really) says there's a variety of reasons, but there's no conclusive evidence:

"It is the question we are asked most often – why is the situation so bad in sub-Saharan Africa? It is a combination of factors – more commercial sex workers, more ulcerative sexually transmitted diseases, a young population and concurrent sexual partnerships."

"Sexual behaviour is obviously important but it doesn't seem to explain [all] the differences between populations. Even if the total number of sexual partners [in sub-Saharan Africa] is no greater than in the UK, there seems to be a higher frequency of overlapping sexual partnerships creating sexual networks that, from an epidemiological point of view, are more efficient at spreading infection."

Low rates of circumcision, which is protective, and high rates of genital herpes, which causes ulcers on the genitals through which the virus can enter the body, also contributed to Africa's heterosexual epidemic.

But the factors driving HIV were still not fully understood, he said.

"The impact of HIV is so heterogeneous. In the US , the rate of infection among men in Washington DC is well over 100 times higher than in North Dakota, the region with the lowest rate. That is in one country. How do you explain such differences?"

Inaction by African leaders has to be added to the list of reasons. Most infamously, Thabo Mbeki, the president of South Africa from 1999-2008, denied that AIDS was caused by HIV for years. His health minister Manto Tshabalala-Msimang said that AIDS should be treated with beetroot and garlic. Harvard estimated Mbeki's inaction caused 330,000 deaths and 35,000 infant HIV infections.

Strangely, this ties into a German vitamin salesman named Matthias Rath who was associated with Tshabalala-Msimang. He promoted the idea (among many other atrocities) that vitamins would prevent or cure AIDS while ARVs (anti-retroviral drugs) would make it worse, and tended to sue anyone who pointed out the obvious falsehoods. If you've got a strong stomach, I highly recommend this free chapter of a Ben Goldacre (who was also sued) book about Rath. It's horrifying stuff.

For further information check this article. It's a bit more comprehensive but has some good information. The author points out several different issues that contributed to the AIDS crisis.

-Comparison to successful countries like Senegal shows where Southern Africa went wrong. Senegal took action early, confronted cultural taboos, promoted condom use heavily, and provided universal access to ARVs. I think the quick action part is particularly important. Pandemics grow exponentially, and lost years from idiot politicians and sociopathic "natural remedy" peddlers cost lives, but determined action can work even in poor countries.

-Global financial aid specifically for health care works. Most AIDS treatment is expensive, and health care is among the first things to be cut in a cash-strapped country.

-Nobody in the West pays much attention to Africa. Once it was clear there would be no heterosexual epidemic in rich countries, attention to AIDS in the media plummeted.

-Pharmaceutical companies are trying to profit from the epidemic and so (somewhat) restricting access of drugs to those who can pay.

-Africa is poor. Poverty is correlated with many different things that increase the spread of AIDS.

This isn't meant to be comprehensive, but I'm getting a picture of Southern Africa as HIV taking advantage of a perfect storm of ignorance, delay, poverty, and dangerous sexual behavior. What makes Southern Africa worse than the rest of sub-Saharan Africa seems to be Mbeki's foot-dragging and Rath's anti-activism. South Africa is the biggest player in the area (indeed, in the whole continent), with gigantic commerce with all neighboring countries, and it's easy to imagine their epidemic spilling over.

Image credit: Wikipedia/Creative Commons