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S. Page, Development, Sexual Cultural Practices and HIV/AIDS in Africa, https://doi.org/10.1007/978-3-030-04119-9_6

in abundance, raising and spending millions of pounds on prevention, and although the number of new infections had been falling (UNAIDS 2010) there is not much evidence that policy (Ainsworth and Teokul 2000) nor prevention programmes have been effective (Potts et al.

2008). As Chin argues, HIV prevention programmes have only received limited success (Chin 2007). I present three examples to demon-strate how policy and prevention programmes are not working. Firstly, Ainsworth and Teokul (2000) state:

[T]here are remarkably few policy success stories on a national scale.

Thailand is the clearest case: after an intense national campaign to raise condom use in commercial sex, the condom use rate for brothel-based sex workers reached more than 90%, STD cased declined precipitously, and HIV prevalence among army conscripts dropped by more than half.

Infection rates among pregnant women have since declined, although are still high at 1-2%, and these accomplishments seem mostly sustained throughout the East Asian financial crisis. In Uganda, HIV prevalence has declined among pregnant women and young people who are delaying sex-ual activity. However, it is difficult to attribute either of these outcomes to public policy. The decline in prevalence may be due to heightened mor-tality among HIV-positive individuals or the natural evolution of human behaviour faced with a generation of high mortality associated with sexual behaviour. (Ainsworth and Teokul 2000, p. 55)

Second, a mathematical modelling tool, known as the modes of transmis-sion model, is used by decitransmis-sion-makers to target measures for preventing HIV infection. The model estimates the number of new HIV infections that will be acquired over the ensuing year by individuals in risk groups that have been identified in a given population using data on the size of the groups, the aggregate risk behaviour in each group, the current prev-alence of HIV infection among the sexual or injecting drug partners of individuals in each group and the probability of HIV transmission asso-ciated with different risk behaviours (Case et al. 2012). There is evidence from modelling that incidence tended to peak around the mid-late 1990s (Shelton et al. 2006), before much was done regarding HIV preven-tion. For example, in Malawi the models show incidence peaked in 1997 at 1.91 and by 2011 it was 0.45, but little donor money for AIDS had come into the country before 1997, and the NAC was not formed and active until well after 2000.

Third, money has kept Persons Living With AIDs alive via Anti-retroviral Therapy, and that might have some prevention impact by

lowering viral load, but it is not yet known how much this has contrib-uted to reducing incidence, and in the longer run it might not matter much if inconsistent adherence produces mutations in the virus that can-cel these effects.

UNAIDS, a programme established in 1996 by six UN agencies to follow on from the work of the World Health organisation’s Global Programme on AIDS in 1987, was an attempt to coordinate efforts to curb the pandemic. The UN Millennium Declaration, signed by the majority of world leaders, put HIV/AIDS at the top of the inter-national policy agenda. At the first-ever Special Session on HIV/AIDS of the United Nations General Assembly (UNGASS) in 2001, UN Member States strengthened the response to Millennium Development Goal 6 by unanimously endorsing the Declaration of Commitment on HIV/AIDS. This Declaration included time-bound pledges to gen-erate measurable action and concrete progress in the AIDS response.

At the five-year review of the implementation of the Declaration of Commitment in 2006, UN Member States reaffirmed the pledges made at the 2001 Special Session. Also, in the Political Declaration on HIV/AIDS, they committed to taking action to move towards uni-versal access to HIV prevention, treatment, care and support by 2010 (UNAIDS 2008).

Despite such efforts, the reaction of policymakers in the Global South has been incredibly varied. Some have placed AIDS at the top of the policy agenda and established National AIDS Commissions. However, where National AIDS Commissions have been created the problem has not been fixed (Putzel 2004). Studies refer to the success stories of Senegal and Uganda and claim that infection rates were reduced due to political leadership (Putzel 2003; Moran 2004; Putzel et al. 2006; Foley 2010). South Africa, by contrast, witnessed some of the highest preva-lence rates in the world due to the reluctance of politicians to act upon the evidence and respond to the disease. The National Party had ‘little incentive to mobilize public resources to counter its impact’ (Fourie 2006, p. 52), particularly as the virus appeared primarily in marginalised groups, such as sex workers and white gay men.

The biomedical evidence tells us about the causes of the disease and how to stop it from spreading. It is accepted in global health policy cir-cles that it is sexually transmitted and that it can be prevented by absti-nence, mutual fidelity in a partnership that is concordant seronegative or consistent competent condom use. Yet politicians can only take effective action if they take on board the epidemiological characteristics of the

virus. The questions that emerge from my research are: (1) Why has the biomedical view failed to dominate the prevention discourses in Malawi?

(2) Why has the international policy community strayed from this knowl-edge and adopted the narratives of blame constructed by the elite in Malawi?

In most countries in the Global South, AIDS is on the policy agenda.

In Malawi policies and programmes on AIDS and sexual cultural prac-tices are not informed by evidence. If this is the case in Malawi is it also true elsewhere? Stakeholders and policymakers think they have evidence, as my interviews presented above highlight. For example, data coming from misreporting, from advocacy documents such as those produced by development agencies or from focus groups and surveys that are small scale are then used to quantify large claims about the causes and reasons for Malawi’s high transmission rate. There also seems to be an overem-phasis on quantitative data and that numbers provide more ‘evidence’

than qualitative data. A senior manager working for DFID told me:

‘DFID pushes numbers. Much more so than we did in the past’ (P30).

Another respondent working for USAID informed me that a problem was that people do not accept qualitative, ethnographic studies as evi-dence (P32). However, it is the qualitative analysis of local peoples’

perceptions and knowledge around AIDS and attitudes towards sexual behaviour that give us a much more in-depth picture of how prevalent

‘at risk’ behaviour actually is and offer possible ways of challenging or breaking cycles of transmission.

Local NGos are asked to generate numbers, which they dutifully do, but the qualitative analysis that seeks to understand why people hold the views they do is rarely done. In other words, the data on transmission are stark, we can accept it is high, but understanding why it is so is left to the Malawian elite to interpret rather than a rigorous process of sys-tematic ethnographic qualitative research. INGos presented with the data turn to the elites and ask them to explain it; the narratives of blame have thereby been constructed and presented as the ‘why’ transmission is high. My interviews and analysis show that the international community then accepts these interpretations which in turn take on a certain ‘myth-ical truth’ about transmission rates in Malawi. My data reveal that those national actors asked, for example by DFID, to come up with explana-tions for the high prevalence do so with vested interests—for example and as Chapters 4 and 5 have shown, they are also driven by religious beliefs and/or by financial incentives. It is hardly surprising that the

resulting HIV prevention programmes are largely ineffective in curb-ing transmission—they simply do not get to the root of the problem as defined through and by the biomedical evidence.