The Origins of AIDS

by Pepin

  The graphic in Figure 7 illustrates the fluctuating patterns of migration into Kinshasa as well as its relationship to the number of people born in the city. It was based on the 1967 survey, and therefore those migrants who did not stay or died were not counted (which means that the number of migrants in earlier years was substantially underestimated compared to more recent periods). It shows the strong migrations experienced during and after WWII, a temporary decrease during the recession of the late 1950s, and then a huge increase immediately after independence. During these same periods the number of births in Kinshasa increased steadily so that by the mid-1950s it was about equal to the number of migrations.

  Figure 7 Migrations and births in Léopoldville–Kinshasa.

  A short journey

  The links between Brazzaville and Léopoldville have been so strong for such a long time that they are in essence two components of a single conurbation, and this should be taken into account when we assemble the puzzle at the end of this book. Their geographic proximity is illustrated in the satellite photograph shown in Figure 8. At this point, the Congo is six kilometres wide. Most of the intercity traffic was carried by a company called FIMA, from the names of its two Italian owners. FIMA operated a dozen boats of different sizes, including a large one that could take automobiles, built by the Léopoldville shipyard. A regular ticket cost 25 francs, and there was a never-ending queue at the counter from early morning till mid-afternoon, with two or three departures each hour. In addition, it was possible to cross the Congo in dugout canoes to visit relatives, trade various goods, avoid payment of taxes or conscription, be forgotten for a while after a brush with the law, etc. One just had to hire a fisherman for an hour.73,74

  Figure 8 Satellite photograph of Kinshasa and Brazzaville, early twenty-first century.

  From the NASA Visible Earth catalogue (http://visibleearth.nasa.gov).

  During the post-war era, for a musician to be considered truly successful, he had to perform regularly on both sides of the river, and popular music, which was completely out of the control of the European colonists, became a further unifying factor between the twin cities. Starting in 1949, football games between sponsored teams of Léopoldville and Brazzaville were held regularly, and thousands of supporters could travel to the other side to cheer on their own team. Ideas were also exchanged, and the relative freedom and less blatant racism of Brazzaville led many visitors from Léo to realise that their own situation was no longer acceptable. Some of these migrations were more permanent, and already in the post-war years Léo had the largest population of Moyen-Congo nationals after Brazzaville. The extent of this interpenetration was revealed in times of crisis. In August 1964, in the midst of a dispute with the leftist government of Congo-Brazzaville, the Tshombe government of Congo-Léopoldville forcibly expelled from its capital all nationals of the former country. Over just a few days, 100,000 individuals crossed the river to the safety of Brazzaville. Later, as the economic situation of Zaire deteriorated during Mobutu’s corrupt and incompetent dictatorship, mass migrations occurred mostly the other way. By the end of the 1980s 300,000 Zaireans were thought to be living in Brazzaville.73

  Meanwhile in Cameroun

  There, the largest city had always been the port of Douala. Possibly because it was a mandated territory, there was little attempt to limit the movement of women to the cities. Compared to Yaoundé, Douala’s demographic boom occurred earlier, immediately after WWII. Its population stabilised around 40,000 in 1936–46, and then shot up to 100,000 in the early 1950s and to 120,000 in 1957. The male/female ratio varied between 1.2 and 1.35 during WWII, increasing to 1.7 during the post-war period when Douala attracted many male migrants, but quickly decreased to 1.2 in 1958.75

  Yaoundé was established by the Germans in 1889 as a trading post. In 1916, it was the meeting point of the French and British armies that took Kamerun from the Germans. Five years later, Yaoundé rather than Douala was chosen as the political capital of Cameroun Français, because it was more central, cooler and more comfortable for Europeans, but also because it was deemed safer should the Germans try to return. While Douala remained the economic metropolis, Yaoundé became a quiet city of civil servants, with only 6,500 inhabitants in 1933. From 29,000 in 1952, its population increased more rapidly with the post-war economic boom, to 54,000 inhabitants five years later. There was a large influx of men, while the women followed a few years later. The male/female ratio was as high as 3.1 in 1955, quickly declining to 1.3 in 1957. After Cameroun became independent, the population of Yaoundé increased from 70,000 in 1960 to 300,000 twenty-five years later, while its male/female ratio remained around 1.2.75–76

  Thus, in all urban centres located near the habitat of the P.t. troglodytes chimpanzee, a gender imbalance resulted from the population policies of the colonial powers, and from the very nature of these booming towns which attracted male migrants in search of a better life. This excess of males was more severe, for a longer period of time, in Léopoldville. In the next chapter we will see how various types of prostitution emerged to satisfy the sexual needs of these lonely men, the perfect breeding ground for the sexual amplification of HIV-1.

  6 The oldest trade

  Prostitution facilitates the spread of all sexually transmitted microbial agents. There is no doubt that it played a crucial role in the dissemination of HIV-1 in many parts of the world, including during the first few decades of the emerging epidemic in central Africa. In this chapter, we will review what is known about the development of prostitution (or sex work, as some prefer to call it) in the burgeoning cities located close to the natural habitat of the P.t. troglodytes source of SIVcpz/HIV-1, a process that was intimately related to the urbanisation we have just examined.

  The core group

  Immediately after the African HIV epidemic was recognised in the mid-1980s, prostitutes and their clients were identified in many countries as the core group within which the virus is exponentially transmitted in the early stages, a process facilitated by the extraordinary prevalence of STDs among these women, which increase the efficacy of heterosexual HIV transmission. Eventually, male clients infect their subsequent female partners not involved in the sex trade, enabling the virus to move out of the core group and into the general adult population. From a concentrated epidemic, it becomes a generalised one.

  It is only recently, however, that the contribution of transactional sex to the overall dynamics of HIV transmission in large African cities has been quantified, following reliable assays for detecting anti-HIV antibodies in specimens obtained from clients having just paid for sex. In Accra and Cotonou, such measures revealed that roughly three-quarters of all cases of HIV infection among men had been acquired from prostitutes. In West Africa, HIV prevalence in the adult male population remains generally ≤ 3%, while it ranges between 5% and 15% among clients of sex workers and between 20% and 75% among the sex workers themselves. When HIV becomes highly prevalent, as in some countries of southern Africa where 35% of adult women are HIV-infected, a lower fraction of cases of HIV in men are acquired from prostitutes because then any sexual activity becomes risky.1–2

  The extraordinary rapidity with which HIV disseminated among sex workers was documented by chance in Nairobi, where several hundreds had been followed since 1980 for a study of chancroid, an STD which causes large and painful ulcerations of the genitalia. Specimens of serum had been kept frozen and were tested for HIV antibodies retrospectively. In 1981, only 4% of Nairobi prostitutes were HIV-infected. Just two years later, more than two-thirds of them were HIV-infected. Among men who consulted in an STD clinic, many of whom were clients of sex workers (from whom they had usually acquired their STDs), none was HIV-infected in 1980, 6% were in 1982 and 15% in 1985.3

  What happened? The Nairobi sex workers had on average 1,400 paid intercourses per year, and condoms were rarely used. Once an initial HIV-infected client infected a first prostitute, this woman developed a high viraemia lasting a few weeks, corresponding t
o what is now called ‘primary’ HIV infection. During this period, she shed large amounts of HIV in her genital secretions, and the pathogen was transmitted to a few of her clients, who in turn developed a transient period of high viraemia. This augmented the number of HIV-infected clients who then transmitted the virus to other, previously uninfected, sex workers, further increasing the risk of transmitting HIV to subsequent clients. An extremely effective vicious circle was created.

  Because of these findings, it has been long assumed that prostitution was the key determinant of the emergence of HIV in central Africa before 1981: the urbanisation and the social disruptions caused by colonisation led to urban prostitution, which then sexually amplified HIV once it had been introduced into this core group, from an initial cut hunter who had migrated to the city.

  Before we review what might really have happened, I want to make a fundamental point: there are many levels of prostitution, loosely defined as the exchange of sex for money or gifts. The Nairobi prostitutes described above, as well as those studied in many other cities of Africa, from Kinshasa to Kigali and Abidjan to Accra, are at one end of the spectrum, and constitute the high-risk group. They have no income other than from prostitution. Because they are older and less attractive, they need to service several clients a day to make ends meet. They live from day to day and are unable to save much. Each client pays as little as $0.50–1.00 per intercourse and the transaction takes half an hour, sometimes less. They cannot afford to refuse any client. These women accept themselves as prostitutes, and do not care whether the rest of society sees them as such. Poverty aside, this is similar to the prostitution that has existed for a long time in the red light districts of Amsterdam and other European cities.

  At the other end of the spectrum, in the low-risk group, is the college student who has sex with two older men each month, to help pay her tuition fees. These men have sex repeatedly with the same girl, once or twice a month, over a long period of time, a grey zone between concomitant partnerships and soft prostitution. The risk of that girl acquiring HIV from one of her sugar daddies is low. If the prevalence of HIV among men is 5–7%, as in mid-1980s Kinshasa, there is a high probability that none of her two regular and exclusive clients is actually HIV-infected, and the girl’s risk would be zero, until she is exposed to other men.

  Also in this low-risk category, which was the rule rather than the exception in central African cities from the 1930s to the 1950s, a ‘free woman’ would have, say, two or three regular patrons with whom she would spend several hours during each visit, not only having sex but also talking, washing their clothes and cooking. If HIV prevalence among clients of free women in colonial Léopoldville was 0.1%, and assuming that each free woman had on average three regular patrons, then for 99.7% of free women the risk of acquiring HIV would have been zero. The initial SIVcpz-infected client may infect the free woman with whom he is regularly having sex, and she may then infect another of her regular patrons with whom she is having a concomitant relationship. But for the virus to spread outside this closed unit, the HIV-infected man must have sex with another free woman, or the infected free woman must develop a relationship with new clients. So the potential for some amplification of a sexually transmitted virus existed, but the vicious circle would have needed a long time to develop, or may not have developed at all.

  In between these extremes, there is a heterogeneous group of mid-level prostitutes, whose risk of acquiring HIV is higher than the free women but much lower than the old sex workers from a Nairobi slum. This category includes the high-class prostitute who picks up one or two rich clients per week, with whom she will spend the whole night, or the woman who has another full-time occupation (say, as a bartender) but complements her meagre income with a few clients.

  Hospitality and housekeeping

  How much prostitution, loosely defined, was there in central Africa in the first half of the twentieth century? Information about prostitution in AEF, Cameroun and the Belgian Congo can be retrieved from the few books and articles published on the topic, from the annual reports of the health systems and, for Cameroun, from the annual reports sent to the League of Nations and the UN. The quality of the information varied. It is easy to find information about the regulations and laws concerning prostitution, but much less about how these rules were implemented in practice. Reports of the French colonial health systems contained a section on ‘social diseases’, which included STDs (syphilis, gonorrhoea and others). The authors sometimes added comments about prostitution, which must be viewed with caution given the overtly racist nature of these reports before WWII.

  Did prostitution exist before colonisation? As might be expected from the diversity of ethnic groups and cultures, there was substantial heterogeneity in sexual customs. Observers writing about Cameroun and Gabon noted that the status of women was deplorable. Becoming a prostitute, as this concept is usually understood, implied a degree of freedom which simply did not exist initially. In some ethnic groups, a woman was considered property, for which a bridewealth payment had been made to her family. The husband, especially if polygamous, could dispose of his property as he wished. One of the wives could be asked to have sex with a friend, a relative or visitor, often for payment to the husband in cash or in kind but sometimes for free, in what corresponded more to ‘sexual hospitality’ than prostitution.4–7

  In the Belgian Congo, early social scientists described traditional forms of prostitution among the Baluba of the Kasaï region. Among the Babunda and Bapende of the Kwango region, east of Léo, fifteen to twenty young men might get together to hire a prostitute (mobanda) for up to two months, and payment (in rolls of salt) was made to the girl’s mother. The young woman would do this only once in her life; it was not considered dishonourable and would not decrease her chances of getting married later. In other areas, a polygamous man could ‘rent’ one of his wives to another man for a predetermined period of time, for a fee. Among the Baholoholo of the western shore of Lake Tanganyika, some villages were specialised in prostitution. These practices were uncommon, but the concept of romantic love was the exception rather than the rule. Missionaries identified the development of Christian-type families as a top priority.8–9

  A different type of prostitution emerged with the arrival of the white man. As early as 1884–5, during Brazza’s second expedition to the pool, his own brother Giacomo and another Italian man took ‘wives’ within days of their arrival, paying five francs per month in local commodities. In the first decades of colonial rule, up to 95% of the European population in central Africa was male, and they could easily find concubines, in exchange for money or other material advantages for the women or their relatives. A well-known euphemism in the early history of the Belgian Congo was the ménagère (housekeeper), who in practice provided sexual services, in addition to cooking, doing the laundry, etc. In Brazzaville, many Europeans also sought comfort from their ménagères, mostly Gabonese women who had been in contact with Europeans for a longer period than those living in the interior and spoke a bit of French.4,10–13

  Father Arthur Vermeersch, a Jesuit theologian, described the ménagère as ‘the illegitimate companion, hired by the month at 25 francs, or for the whole term according to some pre-determined fee’. Europeans vacating their posts would provide newcomers with a ménagère, along with the house and furniture, while others were sent by the village chief, who got paid for it. Once this deal had been done, the woman kept the payments received from the white man, in cash or in kind. Some ménagères enjoyed this new-found power and relative wealth. Vermeersch observed: ‘In the kingdom of the blind, the one-eyed man is king; in the country of the negresses, the ménagère is queen.’ Some Europeans, in line with local customs, entertained more than one ménagère. Of course, the missionaries disapproved of such behaviour. Vermeersch, one of the few prominent Catholics who dared to criticise publicly the leopoldian system, saw this form of prostitution as one part of a larger process in which European colonists were sudden
ly freed from all the social and moral restrictions of the societies in which they had grown up, and which led to the atrocities of the EIC period. He probably had a valid point.14

  A European colonist could easily recruit another ménagère if no longer satisfied by the current one. And a ménagère may, over the years, have sequential relationships with several Europeans, as they left the colony at the end of their term. Women in search of a patron would move temporarily to Boma and Matadi, where the boats arrived from Antwerp. It would have been very much against the ménagère’s interests to have concomitant sexual relationships with African men: giving birth to a black baby would bring her current lucrative relationship to an abrupt end.

  This phase in the history of prostitution in central Africa probably played no direct role in the emergence of HIV-1. It would have been highly unlikely for any European man to have acquired SIVcpz while hunting or butchering a chimpanzee and to start a chain of transmission. And even if HIV-1 had been introduced by one of the ménagères, who perhaps had cut up some chimpanzee meat, the rate of partner exchange was too low for a sexually driven epidemic to develop. However, this phenomenon played an indirect role, by setting an example. For many African women, it became apparent that instead of staying in their native areas and having unpaid intercourse with a husband they disliked, who had made a deal with their own relatives, they could move into these new cities and out of their traditional status of female subordination. While still having sex with men they did not like, they at least got some income out of it and lived freely once these paying partners had returned to Europe. Furthermore, despite vigorous attempts by Catholic and Protestant missionaries, the colonists could not in all conscience repress prostitution among the natives when large numbers of them entertained similar relationships.