The Origins of AIDS

by Pepin

  The writers for the Voix du Congolais identified multiple and interconnected causes of prostitution: the emancipation of women from their previous status as inferior human beings whose lives were controlled by their clan, a process that had been driven by conversions to Christianity; prior to this, all women were married off by their clan at a young age, even before puberty, and thus when deviant behaviour occurred it was by definition adultery rather than prostitution; migration to urban centres and the ensuing erosion of respect for ancestral customs; the behaviour of European men, many free women having started their careers with an affair with an expatriate and discovering that this type of life was far better than their traditional fate; materialism and greed, when the young women and/or their parents discovered the joy of having money to spend; the excessive price of bridewealth, which made it difficult for young men to marry and left many young women without a financially suitable husband; the proliferation of bars of all kinds; and the lack of employment opportunities for women, which was related to their illiteracy. From their discussions, it is clear that free women concentrated on two or three men, some of whom were married. They often confronted the legitimate wives, hoping that a divorce would ensue and that they would get a more regular income from the man. Having hurried intercourses with a large number of men never crossed their minds.

  The solutions proposed varied considerably: increase the tax on unmarried women or eliminate it completely; make the mutation passport harder to get or, the opposite and probably wiser approach, allow all women into the cities to correct the male/female imbalance; fine parents who encouraged their daughters to get into prostitution; control the activities of bars where underage girls and boys should no longer be admitted; improve the educational status of women to make it easier for them to find jobs and other sources of income; and regulate the price of bridewealth. Some proposals were clearly impractical, such as expelling all unmarried women from urban centres, forcing them to take up farming, or stopping the rural exodus completely. Of course, none of their recommendations was ever implemented.

  Across the river

  Prostitution also developed early in the history of Brazzaville. In 1914, there were a few hundred prostitutes, mostly from the upper Congo, at least according to a Swedish missionary. Unless this estimate was exaggerated by an observer concerned with moral issues, it represented a substantial fraction of the city’s population, then around 6,000. At the same time, Mgr Augouard, Brazzaville’s powerful Catholic bishop, expressed concern that mulatto girls, themselves born of a peculiar form of prostitution, would end up practising the same trade as their mothers. Augouard complained that the debauchery of many colonial officers provided a terrible example for the Africans he was trying to convert to Catholicism.12,63

  By a strange paradox, the work of Augouard and his fellow missionaries led to unexpected outcomes. Missionaries had fought to get rid of the internal domestic slavery, and they thought the fate of married women was not much better: they were some kind of marital commodity, which made it impossible for children to be raised in truly Christian families. Thus missionaries pushed hard for the emancipation of women and the abolition of polygamy, directly and through the colonial authorities, while nuns developed activities aimed at improving the status of women. Many of the traditional and repressive customs towards women were made illegal, but this new-found freedom apparently led to some degree of licentiousness. No longer forced to have sexual relations with a man selected by their kin, some women opted for something that was easier to attain than the proposed idealistic monogamous union based on love and the Ten Commandments: the trade of sexual services.63–64

  By stepping up demand, the building of the CFCO railway fuelled prostitution in the AEF capital, while the economic depression of the 1930s increased the number of women who sought to supplement their family’s income and pay their head taxes through transactional sex. Demographically, the surplus of males was more pronounced in Poto-Poto (1.68 men per woman) than in Bacongo (1.13), the other large African settlement of Brazza where, as in Léo, women were considered to have the upper hand. During the late 1940s in Poto-Poto, a district inhabited by migrants, 60% of men aged eighteen to forty were unmarried, a proportion similar to that of contemporary Léo, but only 4% of women lived alone or with other adult women, compared to 12% in Léo. As a percentage of the population, prostitutes were less numerous in Brazza, where urban prostitution was also seen to be both a cause and a consequence of infertility.65–66

  The organisation of prostitution in Brazzaville did not differ much from that in Léo, and some of the sex workers moved back and forth between the two cities, according to which they considered the most lucrative market. Any sexually transmitted pathogen, including HIV, introduced on one side of the river would swiftly reach the other side. Higher-class prostitutes formed mutual aid associations, which conducted negotiations with bar owners and were known under various proper names: Lolita, Dollar, Élégance, Diamant. Similar associations existed in Léopoldville, under similar names: La Beauté, Les Diamants, etc. Free women were proud to show each other how much wealth, fancy clothes and jewellery they had acquired on their own from their trade. For some, it was a very lucrative business: they could bring their parents up to 5,000 francs ($100) per month, a huge amount of money at the time, and naturally fathers would not ask too many questions about the source of such a godsend.12

  Official policies towards prostitution fluctuated over time. In 1940 it was decreed that prostitutes must not only be registered but also photographed and fingerprinted and have compulsory medical examinations. Prostitutes who refused to comply would be jailed for up to three months. Just a few years later, in the midst of WWII, officially authorised brothels were opened to cater to the soldiers waiting to be sent to the frontline (in this case, Libya). The best known was called La Visite and was owned by a Madame Rose from Cabinda. After the war, brothels were again made illegal and prostitution returned to the informal sector, but the proliferation of bars and dance halls provided new venues for a flourishing sex trade.12,65–67

  In the Catholic newspaper La Semaine de l’AEF, prostitution in Brazzaville was scrutinised in articles published in 1955. The causes were the same as in Léo, and the proposed solutions also went along the same lines. There was more of an emphasis, however, on the associations of free women, which either operated small brothels or were closely associated with specific bars which used their presence in their advertisements aiming to attract clients. The correspondents proposed to disband such associations. A more stringent control of free women crossing the river from Léopoldville was advocated.68

  Independence: for whom?

  We have seen in the previous chapter that shortly after the Belgian Congo’s independence in 1960, the population of Léopoldville expanded rapidly. Administrative controls over migrations were abandoned and the capital had to cope with a large influx of internal refugees fleeing the country’s civil wars. And a large number of Bakongo from Angola took shelter in Léo when war broke out between liberation movements and the Portuguese army.

  In a study of Léopoldville sex workers in 1962–3, Jean La Fontaine noted that the vast majority were still operating as they had done prior to the country’s political independence; namely, having long-term simultaneous relationships with three or four men, with the free woman providing a variety of services similar to those that would have been expected of a wife and having some kind of friendship with her patrons, who provided general and regular support rather than a fixed fee for each intercourse. Their most important skill was to avoid having two clients present in their compound at the same time. Free women were considerably wealthier than married women. But La Fontaine also noted a diversification of prostitutes: at one end, the luxury prostitutes, called vedettes or basi ya kilo (the latter because they could buy expensive goods by the kilogram, especially those who had recycled their income from prostitution into the trade of other goods); and at the other end, the chambres d’hôtel p
rostitutes, who could have a quick half-hour session without much conversation being exchanged. This is the first description of high-risk prostitutes for whom sex was a purely commercial transaction. Anatole Romaniuk, a demographer who worked in Léopoldville before and after 1960, also described a change in the character and volume of prostitution as a consequence of the political disorders, as did sociologist Alf Schwarz, who studied women working in the Léo factories, many of whom had previously been involved in the sex trade.11,52,69

  Paul Raymaekers, an observer of life in the surrounding squatter areas of Léopoldville, noted the same phenomenon, which he attributed to social changes and high unemployment rates, but he provided more details. A new form of prostitution clearly emerged in Léo in 1960–1, around brothels called ‘flamingos’, from the name of the first bar where this began. Initially the flamingos were clandestine bars where alcohol could be bought after hours, but soon their activities were expanded to include the sex trade, by setting up discreet annexes for this purpose. In the Matete area, of 708 houses enumerated, there were no less than twenty-seven flamingos. Similar concentrations of flamingos were found in many other parts of Léo, including Ngiri-Ngiri, Barumbu, in front of the Makala sanatorium, etc. The downmarket brothels, called londone, were small shacks with one or two rooms, quickly set up on some unoccupied piece of land, often near the street markets. Outside, men could be seen patiently queuing for their twenty minutes of pleasure. At the opposite end of the spectrum were the flamingos frequented by the Congolese elite and UN military. The law of supply and demand dictated lower prices if the client was unemployed and higher prices after pay day or if the UN soldiers came from an industrialised country. Among an admittedly small sample of twenty young men interviewed, all knew at least five flamingos and thirteen admitted to having bought sex on at least one occasion. Also reflecting the extent of this new phenomenon, a wide diversity of Lingala or Kikongo terms appeared describing sex workers: londoniennes, boma l’heure (kills time), molaso (rubber band), katula kiadi (removes sadness), mobikisi (helper), Good Year or Caterpillar (good for all conditions . . .).55,70–72

  In a study of women in Léopoldville conducted in 1965, Suzanne Comhaire-Sylvain also noted the extraordinary proliferation of flamingos: just in the Matete district, out of about a hundred bars where alcohol was sold, sex could also be bought in eighty. In the Bandalungwa district, there were at least twenty such dance halls/brothels, usually well located at crossroads or near open air markets or gas stations. Others were situated in residential streets, and it was just too bad for the neighbours. Comhaire-Sylvain described a diversification in the patterns of sex trade and identified four categories. First were the full-time sex workers, unmarried or divorced women who would spend many hours each day picking up clients in a flamingo or bar or on the street. Although she did not provide estimates of their average number of clients per day or per week, this type of practice implies quite a high volume (and high risk). Second were the part-time sex workers: unmarried or divorced women who had another occupation but sold sexual services once in a while to supplement their income. Third were the clandestine sex workers: teenagers or married women who sold sex occasionally without their parents or husbands being aware of this lucrative part-time activity. The latter two categories implied a low volume of clients, and a different client each time. Fourth were the free women, corresponding to the lowest risk for HIV: these upmarket semi-prostitutes had just a few paying partners, whom they had the luxury of selecting and who would enjoy their company regularly.73

  Thus in the early 1960s there appeared for the first time in Léopoldville a group of women having not three or four different sex partners per year but three or four per day, a pattern of prostitution similar to the one in Nairobi which led to the exponential amplification of HIV-1 twenty years later. Once a first high-risk sex worker got HIV-1 from a client, in the ensuing months she would have the opportunity to infect a few other men, some of whom would then infect other prostitutes they had sex with. The conditions of a sexual amplification of HIV were ripe, possibly the turning point in the sexual spread of HIV-1 in Léopoldville.

  This evolution was a consequence of the enormous social changes that occurred after 1960, with a massive influx of refugees and migrants who settled in the capital, and a staggering rise in unemployment. The resulting pauperisation had a profound impact on the sex trade. Potential clients did not have enough money to provide gifts or regular support to a free woman whom they would visit time and again; they barely had a few pennies for a brief session. And poverty among young women had grown so much that some had no option but to accept those few pennies which, multiplied by the number of clients they could fetch in a day, allowed them to satisfy their basic needs. Unlike the free women, this new class of high-volume, low-price sex workers did not have the luxury of turning down a client they disliked.

  In July 1968, the Zairean minister of justice ordered all brothels to be closed. This did not impact on the volume of the sex trade, as the owners simply modified their premises. They added a bar and dance floor, where the clients could select their sex worker over a few beers. Or they pretended they operated a small hotel, where rooms could be rented by the hour. Again, there were no pimps: the owners made their profit on the alcohol or from renting the rooms, and the sex workers kept the money paid by the clients. By the end of the 1960s, the system of health cards for sex workers was still in place, theoretically requiring a monthly visit and syphilis serology twice a year. Prostitutes had to show up at the Centre de Prophylaxie in the compound of the central hospital, and about 7,000 women attended more or less regularly. Health surveillance of prostitutes vanished in the 1970s, as the resources of the Zairean state were eroded by an ever-increasing percentage of national revenues being diverted into the numerous bank accounts of the president and his cronies. But the diversified patterns of prostitution did not change much until the early 1990s, when poverty became so great that few men could afford to buy sex. Hunger and libido are mutually exclusive.74–75

  7 Injections and the transmission of viruses

  Ten years ago, a group of scientists argued that unsterile injections played a role in the emergence of HIV in Africa (and that serial passage of the virus within syringes altered it in a way that made it more virulent and/or more transmissible, something which remains debated among virologists until now).1 As mentioned in the introduction, after studying this question for some time I came to the conclusion that they were right, that a substantial part of the early amplification of HIV-1 in central Africa occurred through the re-use of improperly sterilised syringes and needles, and that this mechanism was probably as important as the sexual amplification which we just reviewed. It will be impossible to prove this directly. But like a crown prosecutor who has not found the exact gun used in a crime, in the next three chapters we will assemble circumstantial evidence that would ultimately convince any jury. We will first examine how HIV but also HBV and HCV can be transmitted through injections.

  Parenteral or iatrogenic

  Parenteral is synonymous with injectable; it literally means to bypass the gut, by administering a drug (therapeutic or recreational) or blood product as an injection, either into a vein (IV), muscle (IM), the tissues underneath the skin (SC) or the skin itself (intradermal (ID)). Iatrogenic means during health care; the transmission of pathogens between intravenous drug users is not included in this latter definition, but non-injection modes of healthcare transmission are (for example, during an organ transplant or some other invasive procedure). In sub-Saharan Africa, there is much overlap between these two terms, parenteral and iatrogenic, because the continent has few drug addicts (such a habit is far too expensive) and few patients undergo invasive medical procedures during which a virus could be transmitted.

  The parenteral transmission of HIV-1 has wiped out a generation of haemophiliacs, infected tens of thousands of recipients of blood transfusions in the late 1970s and early 1980s and continues to be an important mod
e of transmission among injectable drug users (IDUs) throughout the world. In developed countries that have implemented a universal programme of immunisation against HBV, the parenteral transmission of the latter is now uncommon, except among older unvaccinated drug addicts. However, the iatrogenic transmission of HBV continues in developing countries where the vaccine has only recently been incorporated into the national immunisation programme. And transmission of HCV, for which there is no vaccine, continues among IDUs in industrialised societies, as well as in the general population of the developing world. Other viruses can be transmitted parenterally but this occurs infrequently and can be ignored for the sake of our discussion.

  The main difficulty in studying the potential contribution of the iatrogenic or parenteral transmission of HIV-1 in its emergence in the first half of the twentieth century is the high mortality among infected individuals, nearly all of whom die within fifteen years of primary infection. They are no longer available for epidemiological studies trying to correlate HIV-1 infection with ancient exposures to injectable treatments of tropical and other infectious diseases. The only option is to use other infectious agents, which are compatible with prolonged survival, as a proof of concept: if these other viruses were transmitted iatrogenically, then presumably the same could have happened with SIVcpz/HIV-1.2

  HIV-2 infection is an interesting candidate for such studies because of its lower pathogenicity: a substantial percentage of individuals infected with this other simian-turned-human retrovirus, which originated from the sooty mangabey rather than the central chimpanzee, and in West Africa rather than central Africa, never develop AIDS. We carried out an epidemiological study in Guinea-Bissau which revealed that among elderly individuals living in Bissau in 2005, HIV-2 infection was correlated with three distinct parenteral exposures: past treatment with IV or IM drugs for sleeping sickness (before 1974), past treatment of tuberculosis with IM streptomycin (before 1992) and the ritual excision of the clitoris. However, HIV-2 is not present in central Africa and cannot be used as a model for transmission of blood-borne viruses in the very countries where HIV-1 emerged.3–4