Promise of drugs gives Malawians fresh hope - and a reason to get tested for HIV

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The Independent Online

There were six pages of Valentine tributes in The Nation newspaper, Malawi's largest selling daily, last weekend. The messages, each topped by a heart-shaped photo of the intended, had a beguiling innocence about them. There was no innuendo, no lovey-dovey language - just straightforward declarations from the heart. "Your love gives me courage", Phiri told her boyfriend, George Mphasa. "Your love makes me a better man," Henry promised his girl, Grenna.

So romance can flower even in a land where it has brought so much death and suffering. Everyone knows that out of the desire that drives men and women together has come a disease which is destroying Africa. One in four of the lovers who pledged their loyalty to their partners in the pages of The Nation are infected with HIV - and an untold number will break their vows of loyalty and have sex with someone else.

Gordon Brown the Chancellor, warned on Monday that progress towards development in some parts of the world was so slow that it could take more than a century to achieve the millennium goals set for 2015, which include a target of halting the spread of Aids. But Aids cannot be defeated by money, or medical research or international help alone. That will depend on achieving social and cultural change, which could be the toughest challenge of all.

The young urban Malawians who placed their Valentine messages in the newspapers are no different from young people everywhere. They like to drink and dance and flirt. At the Panorama bar, newly built on a hill a few miles outside Blantyre, the band was belting out old rock standards last Friday night and scores of young people were shaking their booty on the open-air dance floor.

George, a large man with a big laugh, returned from the dance floor for another beer. "I am going back," he announced, with a grin. "I am getting lots of offers." Girls with spray-on trousers and plunging necklines eyed the men, approaching strangers as if they were old friends. A bar girl came over to take our order and sat down with her thigh pressed against mine. When I asked, prosaically, where the toilets were, she offered to show me, telling my companions in Chichewe, the local language: "I think I am doing well with him."

Peter, a tall, serious man from Tanzania, described how he took his sister to a bar in Dar es Salaam and was given a frosty reception by the bar girls. "They don't like it if you go there with someone," he said. "They regard every man as a potential client." One of the tragedies of the Aids story is that while vast sums of money have been poured into research aimed at finding a cure for the disease, far less effort has been expended on understanding the social and cultural forces that have fanned the flames of the epidemic.

Alex de Waal, of Justice Africa, has said that faith in medical science may have retarded investment in humbler technologies, such as finding inventive ways to promote the condom; or improving the economic and social position of women. Much more is known about the virological complexities of HIV than the sexual networks and practices that help it to spread.

For 30 years until the early 1990s, Malawi was locked in a time warp under its conservative president, Hastings Banda, who had a fear of the modern world. Long hair for men was banned and women were forbidden from wearing short skirts or trousers. In the decade since Banda's death, many of the restrictions that were strangling development have been loosened - but vestiges remain. Recently in Blantyre, a skimpily dressed woman was set upon by a mob, offended by her provocative attire, stripped naked and run out of town. Her dignity was only saved by a friend who covered her with a blanket.

Some preach abstinence and faithfulness as the only means to curb the epidemic - and there is some evidence that, combined with promotion of condom use, this has had success in reducing infection rates in Uganda.

But this ignores a key cultural feature - the economic dependence of women on men. Women are taught from the earliest age to be subservient to men. In the Panorama bar, the bar girls address their male customers as "Bwana" and give a little curtsy as they are paid. Women are less likely to be educated and less likely to find paid work. That gives men a licence to misbehave and leaves women with no option but to consent to their demands. One 20-year-old woman said: "What are relationships about then? Men are supposed to provide money and other things."

I was in Blantyre to run a course for local journalists on reporting HIV/Aids, organised by the Commonwealth Press Union. While the 18 participants - 14 men and four women from across sub-Saharan Africa - were keen to debate condom use, HIV testing and the provision of antiretroviral drugs, they were less comfortable with discussion of the relationship between the sexes and the need to empower women.

The consequences of this failure are starkly evident. On Hanover Street in Blantyre, a woman approached George, a reporter from Zambia and offered sex for 750 kwacha (£3.75). "Do you have a condom?" George asked her (strictly in the interests of research). She did, she said, adding if he wanted "plain" sex - without a condom - the cost would be double.

But why should people care when life is fraught with risk in any case? Malawians are among the poorest people in Africa and hunger and disease are ever present threats. One in five children dies before the age of five, the eighth highest childhood mortality rate in the world. And malaria claims more lives in Malawi than Aids.

At the Aids clinic at Thyolo hospital, 19 miles south of Blantyre, run by Médecins sans Frontières, 900 men and 898 women were tested for HIV in December; 328 women were positive compared with 206 men, a 60 per cent difference. Women are twice as likely to be infected with HIV as men.

Aids has left 20-year-old Rose Madengu's long limbs skeletal - she weighs slightly more than five stone. She was started on antiretroviral drugs last November - provided free by MSF. She is now much improved, said Dr Patrick Gomani, the medical director. Rose told how her two children died within weeks of birth and her husband "ran away". She had suffered diarrhoea for a year but now that has stopped - another sign that the drugs are working. But the most important benefit the drugs had brought her was hope.

At last, there is a point to getting tested for HIV - because now there is a treatment. Since MSF began offering free treatment last April the number coming for tests has steadily increased. And as testing becomes more widespread, the stigma attached to the disease, and the behaviour with which it is associated, diminishes.

A sign of the change came last week when President Bakili Muzuli launched the government's Aids policy - to provide antiretroviral drugs nationwide from next July. In doing so he made a plea for openness about the disease - and revealed that his own brother had died of Aids.

As the drugs that have been denied for so long become available, for the first time, to secure their future, Malawians may see some point in changing the way they live.


* Population 11.3 million

* 900,000 people aged 15-49 are infected with HIV/Aids

* One in four people infected in urban areas and one in eight in rural areas

* 87,000 died from Aids in 2003

* Teachers are dying at a faster rate than replacements can be trained

* 641,000 people have died since the first case of Aids was identified in 1985

* Target of 50,000 in treatment with antiretroviral drugs by 2005