The Origins of AIDS (12 page)

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 to 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 SIV
_cpz
-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
.

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 suddenly 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 SIV
_cpz
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.

Thousands of mulattoes were born of these loveless unions between Europeans and their
ménagères
. Their fate would depend upon recognition by their father. About 10% were recognised, in which case the fathers would take them back to Belgium at the end of their term, and they would never see their mothers again. The others stayed with their mothers who might have been given a small sum of money for that purpose. The poorest would end up in specialised orphanages set up by Catholic missions
. Mulattoes were treated as Africans by the colonial segregationist system, while being rejected by the Congolese as foreigners
.
^15
–
17

It was not until about 1910, when small cities were created in which the African male population was much larger than the female, that prostitution appeared in which African men were having sex with African women for money or gifts. These women were usually unmarried or divorced. For
some of them, becoming a prostitute was a kind of liberation. They would move to the cities, away from family and societal constraints and values, free to behave as they wished. To this day, it is noteworthy that the
Lingala word
ndumba
can mean either a prostitute, or simply an unmarried woman no longer dependent on her relatives. In Congolese French, this became
femme libre
, a free woman, who had broken away from the control of her guardians, whether husband or kin, and whose life depended on her own intelligence and resourcefulness.

How did soon-to-be-free women manage to reach the city, given the stringent regulations on female migrations described in the preceding chapter? Some convinced a man to marry them and ditched their husband as soon as they got their papers. In other cases, a fake marriage sufficed. The woman showed up at the district office and produced false documents attesting that a
bridewealth had been paid. It was possible to get married without the husband being present.
¹⁸

From these early days, the practice of prostitution in central Africa differed from what was commonplace in Europe. Apart from a few cases where husbands benefited from one of their wives selling sex (they showed up at the European customer’s house, pretending to be angry and asking for compensation to avoid a scandal), free women had no
pimps, either in the 1920s or at any subsequent time during the colonial era or after decolonisation. Until 1960, there were no brothels and clients were not picked up on the street. Male clients visited prostitutes where they lived, and the women provided more than sexual services. This was a low-risk type of prostitution, as defined earlier, or semi-prostitution as it was called by some authors.
⁴