Day One Kasensero, Uganda
It is a rough road to Kasensero on the western shore of Lake Victoria in south west Uganda and a rough town at the end of it. A bone shaking hour after leaving the main Uganda–Tanzania highway, we crested a ridge and got our first glimpse of the “hot zone”, the epicentre of Africa’s Aids epidemic.
The corrugated iron roofs, clustered at the water’s edge, glinted in the afternoon sun. Twenty minutes later we were down among the fishing boats - 40ft long wooden canoes with outboard motors, at least 150 of them – drawn up in tight formation on the beach.
Kasensero may one day become a tourist destination as the site where the first stirrings of the holocaust that has so far claimed 30 million lives around the world were identified in Africa. It was here in the early 1980s that Ugandan researchers spotted a new syndrome they termed “Slim” disease, (because it turned sufferers into walking skeletons) publishing their findings in 1982.
One day tourists may come, perhaps - but not today. The beach was not a comfortable place to be. Red-eyed fishermen, many of them drunk at 4pm, leered at my blonde 25 year old daughter, whom I had brought along as my photographer. Others leaned on their boats, counting out wads of banknotes, as they traded huge silver fish with crimson gills from the day’s catch.
“Take me to London,” joked one man, the alcohol heavy on his breath. “Bring us money,” said another, his friends laughing. “Hey sister,” yelled a third, making a mock lunge at my daughter.
Two years ago Western political leaders began speaking about the “end of Aids”. Barack Obama and Hilary Clinton foresaw a time when the disease might be beaten, and The Economist published an influential article asking if its days were numbered.
Their optimism was based on research that heralded a step change in the battle against the virus. It had shown that the anti-retroviral drugs (ARVs) which had already saved millions of lives also dramatically reduced transmission of the virus, by as much as 96 per cent.
For the first time the world had a weapon that could potentially defeat Aids, but which did not rely on changing sexual behaviour – notoriously difficult to achieve. Every person put on treatment meant one fewer to spread the contagion. In September this year the deputy head of Unaids, Dr Luiz Loures, declared the Aids epidemic could be over by 2030.
It is a pity Mr Obama, Ms Clinton and the rest were not able to visited Kasensero, 250 kilometres south west of Kampala, Uganda’s capital, in Rakai province. Almost 30 years since those first cases of Slim were described, the town now has what is almost certainly the highest level of HIV infection on the planet. And it is rising, not falling.
One in every two women and a third of men carries the virus in Kasensero, according to a 2012 survey by the Rakai Health Science Programme (RHSP). Among sex workers, the prevalence is 75 per cent.
There are no comparable figures from earlier decades but the researchers estimate in the 1990s, 25 per cent of the population of Kasensero was infected, suggesting the prevalence has increased by half, to its present level of 41 per cent, in the last 20 years.
It is a town of shacks and hovels, crumbling in the dust, wholly dependent on the trade in fish. Few among its 30,000 inhabitants are permanent residents and fewer still over 40. Fishing is a risky, uncertain trade suitable only for young, fit men - marauding gangs of them - who are paid daily, in cash, according to that day’s catch. They spend their money on beer, drugs – and sex.
In a hut on the beach, the town’s chairman Lawrence Muganga, described how sex workers from across the border in Tanzania and as far afield as Kampala responded to the demand. “They call their friends and ask: ‘Is business good? If it is a good season [for fishing], there are many coming.”
Tacked to the hut door outside is a sign advertising free condoms but when Mr Muganga pulled down the white cardboard box from where it was stuffed in the eaves, no more than a dozen of the 100 it contained had been taken since it was delivered by the local clinic a week earlier.
“Very many prostitutes come here to sell their bodies. So you have to teach them to use this one to protect themselves,” he said, without conviction.
Behind the beach, rows of curtained doorways concealed the bars and brothels that lined the streets. Jane Namutebi, 31, rented one of the cell-like spaces for 60,000 Ugandan shillings a month (£15).
Wearing a long blue dress, she sat in the gloom with two friends, both in revealing low cut tops. “I am hoping to get a big business. The customers are attracted by the women,” she said, indicating her friends. Bottles of Beckam Gin and Royal Vodka stood on the dusty shelf above her.
She was diagnosed HIV positive a year ago. Her three children are looked after elsewhere by their grandmother. Did she use condoms?
“I had them but they are finished. The customers don’t have enough education for safe sex.”
All along the shores of Lake Victoria, the story is the same. Fishing, by its nature, is uncertain and risky. Fishermen move from place to place, wherever the catch is good. They are young men, with plenty of cash, living in communities with few families, few older people and no constraints. Drownings are common and alcohol cheap and ubiquitous. By comparison with the risk of going out on the lake, the risk of HIV is remote.
“These are very isolated communities with very basic services”, said Asiki Gershim, project leader at the UK Medical Research Council in Masaka, 80km from Kalensero. A recent survey found more than half of fishermen said they had had more than one partner in the previous three months. Serotyping shows fishermen spread the virus into the general population when they return to their home villages. They, not truckers, may be the crucible of the African epidemic.
The story of Aids in Africa has been told as if it were a single epidemic which has swept the continent, mainly – and uniquely – spread through heterosexual sex.
But the truth is, as always, more complex. There are hundreds of separate Aids epidemics in Africa, each following its own trajectory, each with its own drivers.
Rakai province has the highest HIV rate in Uganda, driven by its fishing communities. At 12 per cent it is almost twice the national rate. Across the continent infection rates have fallen dramatically in the last two decades but worryingly, and uniquely, in Uganda the national rate has turned upward again, from a prevalence of 6.4 per cent in 2005 to 7.3 per cent in 2012.
Uganda was the first African country to be hit by Aids in the 1980s, the first to respond, and the first to see a dramatic fall in infections, a pattern since followed by the rest.
The recent resurgence of the virus in the country has aroused fears that it may signal a new continent-wide reversal, putting paid to heady talk in the West about the end of Aids.
“I am very concerned there is complacency,” said Peter Piot, director of the London School of Hygiene and Tropical Medicine and former director of Unaids. “As one commentator said [in response to talk of the end of Aids], what have they been smoking? People are not looking at the complexity of the epidemic. Uganda was the first country that achieved results – it may be the first where we see a rebound, and others follow.”
Special factors are at work in Uganda. The president, Yoweri Museveni, marking his 28th year in power, was the most outspoken leader on Aids in the 1980s, as he watched it decimate his troops. But in recent years his enthusiasm has waned, some say under the influence of his evangelical Christian wife, Janet Museveni, who preaches abstinence.
Kenya, which had a tourist industry to protect, was slow to acknowledge the epidemic in the 1980s and slower still to act. But it was quicker than Uganda to recognise that generalised behaviour change campaigns were failing and it was essential to tackle the disease in key groups such as sex workers, fishermen, truckers, men who have sex with men and injecting drug users.
The result has been a steady fall in new infections in Kenya, one of the great success stories on the continent. Yet even here, 100,000 people are becoming newly infected with HIV each year, almost twice as many as are going on treatment with ARVs.
I heard the same phrase repeated endlessly on my journey – “you cannot mop the floor with the tap still running. “In Uganda, Kenya, Malawi and Zambia 80-100 per cent of Aids funds come from donors. Without further big reductions in new infections the situation is unsustainable.
“We have to try and switch this disease off,” said Dr Clement Chela, director-general of the National Aids Council, in Zambia.
In Nairobi, Pamela, a sex worker, showed us one way that might be achieved. She led us on a winding route through foetid alleyways in the centre of the city to the Somerset Club, an anonymous doorway under an illuminated sign for Tusker beer.
At the top of a flight of stone steps, five women in short skirts and tight trousers sat on a row of chairs, waiting for customers. A tall elegant woman descending from an upper floor grabbed my crotch as she passed. “Muzungu (white man),” she yelled, cackling with laughter.
As we stood chatting to Wilfred, the manager, a chewed matchstick between his lips, there was a sudden flurry of business. The women appeared leading their clients – one a bald man leaning on a crutch – calling to Wilfred as they passed, who handed each two condoms and a piece of tissue, before they disappeared into the bolted cubicles beyond. It was an impressive demonstration of safe sex– and a world away from the brothels of Kasensero.
Prostitution is a feature of every city in the world, but in Africa it has exploded in the last decade, driven by a growing economy and the power imbalance between men and women.
There are an estimated 45,000 sex workers in Nairobi and as the numbers have increased the price of sex has fallen. In Kampala, prostitutes line the streets near the Speke Hotel and sell sex for as little as 3,000 Ugandan shillings (75 pence).
Other countries are witnessing the same trend. “Sex workers are growing,” said Frank Chimbandwira, head of HIV at the Ministry of Health in Malawi. “Mines are opening, roads are being built, men have cash to buy sex – the development agenda brings risks,” said Dr Clement Chela head of HIV in Zambia. “There has been a mushrooming of sex work,” said Maria Sibanyoni, head of the sex workers programme at the University of Witwatersrand in Johannesburg.
Despite these trends, among some groups HIV infection rates are sharply down. In Nairobi, the first clinic for sex workers opened in 1985, and there are now nine across the city offering free condoms, HIV testing and treatment. The incidence of new infections has more than halved since 2005.
Crucial to the success of the strategy has been the recognition, which has been slow to dawn, that professionals are no good for giving advice. They are not listened to. Inroads into the HIV epidemic in Africa have only begun to be made with the appointment of ‘peer educators” – members of the target community who have been trained to pass on the message to their peers.
Pamela, is a respected peer educator, and is known and trusted on her patch. Aged 39, she has a round face and gentle demeanour.
Two minutes after leaving the Somerset Club we are sitting with another sex worker, Mary, in Modern Green, a higher class establishment round the corner. It is 5pm and a dozen women in clinging dresses and earrings, showing cleavage and thigh, are sitting at tables in the dingy upstairs bar.
I buy Mary a Guinness, her second. She says she can drink nine. I pick up the bottle looking for the alcohol content. “6.7 per cent” she shoots back at me, smiling.
She has on a red dress, red earrings and is smart and well spoken. She is 28 and has been a sex worker for five years. Does she use condoms?
“Of course”. She fixes me with a look of horror. “No condom, no sex.”
Behind her a drunk man is fondling a woman who is studiedly ignoring him and reading the paper – until he produces his money. Sex here costs 500 shillings (£4) plus 300 shillings (£2.30) for a room, for ten minutes.
After we leave I ask Pamela about the “no condom, no sex,” claim. It depends, she says, on whether the client or the sex worker are drunk (often both) or whether the client is offering more money for “live sex,” a common demand. “If they are very drunk, they don’t care,” she says.
Yet there is little doubt of the value of what she is doing. Peer educators are now being used across the continent – “expert mothers” trained to promote antenatal care, “expert patients” to advise on treatment with anti-retroviral drugs, “community mobilisers” to bring men for male circumcision, and sex workers like Pamela to promote regular HIV testing, treatment for STIs and condom use. Nothing can be achieved in Africa’s intensely hierarchical society without peer educators.
But while Kenya has done a good job with its marginal populations like sex workers, the challenge remains how to reduce infection rates in the general population where the bulk of transmission occurs.
Most sex workers are infected not by their clients but by their long term partners, when condoms have been dropped. It is the same in the general population – condoms may be fine for casual affairs but their use in a long term relationship signals mistrust.
“It is love and trust that makes women vulnerable. Love is the problem,” says Jane Thiomi, manager at LVCT, a Kenyan HIV organisation.
In Kenyan society, as across the continent, it is accepted that men will have more than one partner – and the wealthier they are the more mistresses they will support.
“Even when the mistress is exposed and the wife goes to her mother to complain, the question the mother will ask is: Is he taking care of you? [Infidelity] is not taken seriously,” says Ms Thiomi.
The frequency of multiple overlapping partnerships is said to be what distinguishes sexual behaviour in sub-Saharan Africa from the rest of the world – and is a key driver of the heterosexual epidemic. Yet its lethal consequences are ignored. A recent advertising campaign urging straying lovers to be careful with the catchline: “Weka condom mpangoni!” (Put a condom in that relationship) was banned after protests from church-based organisations.
“Kenyans are very sexually active, but they don’t talk about it,” said Ms Thiomi.
Few believe sexual behaviour in this regard has changed. With economies growing, more men are able to afford mistresses. While Western leaders proclaim the end of Aids, the drivers of the epidemic in Africa are working in the opposite direction.
At the same time, the forces constraining sex have lessened. In the early years of the epidemic behaviour changed because terror stalked the streets. Those infected became walking skeletons covered in sores who died horribly - and people were going to funerals every weekend. “Now people on treatment are completely healthy. We struggle to explain the dangers to young people who have grown up with HIV – there has been a complete change,” said Peter Kyambade, head of the sexually transmitted disease clinic at Mulago Hospital, Kampala.
Like everyone I met in Uganda he blamed the upsurge in infections in that country on complacency – and warned other countries that they should ignore Uganda’s experience at their peril. HIV had been transformed from a lethal infection with only one outcome into a treatable disease, like diabetes. It was no longer feared as it once had been.
“The disease has been with us a long time. People are relaxed. The focus has been majorly on putting people on antiretroviral drugs. We need to focus on prevention again.”
“If other countries don’t address this issue they will face the same challenge. Their advantage is they can learn from us. We need to go back to our communities and intensify our campaigns. We need to remind them: It is not over yet.”
The falling price of sex
As the number of sex workers grows, the prices they can command fall.
Sex at the Somerset Club in Nairobi , a low grade joint, costs 200 Kenyan shillings (£1.75) for ten minutes.
“Sex work is the only thriving business,” said a manager at the Sex Workers Outreach Project, which runs nine clinics in the city.
It is the same story in Kampala. Sex that used to cost 15,000 - 20,000 Uganda shillings (£3.75-£5) now costs 3,000 (75 pence), according to Kyomya Macklean, a former sex worker and human rights activist.
In Kisumu, Kenya’s third largest city on the eastern shore of Lake Victoria, which has the highest HIV rate in in the country, the price for sex fluctuates. It falls sharply in April, August and December, when the schools are closed and teenage girls take to the streets to top up their mobile phones and pay for essentials like sanitary pads.
“At those times the market becomes flooded,” said Jared Omnudo, Field Co-ordinator at Impact, a local HIV charity.
The writer’s trip was funded by a no-strings grant from the European Journalism Centre