Views & Reviews Personal View

HIV in Africa demands complex cultural responses

BMJ 2013; 346 doi: (Published 29 April 2013) Cite this as: BMJ 2013;346:f2517
  1. Chris Ellis, general practitioner, Pietermaritzburg, KwaZulu-Natal, South Africa
  1. cristobalellis{at}

After a quarter of a century of AIDS in Africa, Chris Ellis reflects on the cultural changes the epidemic has brought—and the future

I practise in the province of KwaZulu-Natal in South Africa, which has one of the highest, if not the highest, incidences of HIV and AIDS in the world. Over the past 25 years we have watched as this epidemic started slowly, gained momentum, and then, overwhelming our social, medical, and economic resources, turned our hospitals into hospices. As antiretroviral drugs became more available, the pictures and prognoses of the epidemic have changed, and we are now seeing a slight downturn in the number of cases.

One recent evening a man came into the surgery carrying a young woman and laid her down. She was in her 20s and easy to carry because her body was so wasted. She died within the hour. The practice nurse and I waited with the corpse for the undertakers. As they dispassionately loaded the frail body into the van, I imagined what it must have been like in medieval England during the black death.

In KwaZulu-Natal alone as many as 200 people a day die from AIDS, but the statistics are almost meaningless because the number of patients in the country being newly infected, the Department of Health says, is approximately 1000 people a day (though this is impossible to verify).

But AIDS is now old news, though interesting ethical dilemmas still arise almost daily. For instance, I have been asked whether I would check teenage girls’ virginity each month. Such virginity inspections have been revived in rural areas, where they are carried out by designated female elders. This revival of an old Zulu custom involves the Princess of the Heavens, Nomkhubulwane, goddess of virginity and fertility. Other cultural beliefs complicate the AIDS epidemic in Africa—for instance, there is a widespread belief that herbalists (izinyanga) can cure AIDS with a mixture of herbs (uzifozonke). The popularity of traditional healers is based on the hope that they give to patients: at a government clinic, a patient finds an institution surrounded by wire fences for security, long queues, and exhausted staff.

For years AIDS was underground. After 25 years it is starting to be discussed in the open, but it has also developed a subculture of euphemistic communication because it involves the two great taboos of sex and death. The Zulu word ingculazi, coined by the radio presenter Thokozane Nene, comprises syllables from several words related to sexually transmitted and incurable disease. HIV is also expressed as “zu three” (representing the three letters HIV), or it is not spoken of at all—three fingers of the right hand are silently raised. I have also heard that the amaXhosa people raise four fingers to represent the four letters AIDS.

The powerlessness of African women is also a problem. The custom of respect, called hlonipha, means that children and women must use a different vocabulary in a world dominated by male elders. There is also the custom of lobola, whereby the groom pays a number of cattle or sum of money to the bride’s parents, which may affect the woman’s further standing in their relationship. There is a pervasive culture of gifts for sex.

Interwoven among all this is the culture of isoka, the lover boy, the veneration of male potency, along with polygamy, and the diminished social status of women. Even educated African businesswomen lead dual lives. By day they command responsible jobs, but at home they tiptoe around in a world of subservient deference.

AIDS has imperceptibly changed the relationships between men and women. One example is bakeepita, derived from the English phrase “keep it,” which is the trend for couples to live together like common law spouses rather than to formally marry. By doing this, if one partner gets AIDS then the other partner is not tied into the relationship. This is said to be a reason for the fall in the number of marriages. Another reason for bakeepita is that the main social gathering for families is now funerals, which use up the money that they would have spent on weddings.

All this exacerbates the problems of our inherited migratory labour system. Migratory labour broke up traditional closed families, creating societies that are potentially more vulnerable to ills such as multiple partners, loneliness, and alcoholism.

Of course, we need antiretrovirals, and facilities to treat complications and opportunistic infections and to care for dying people. But in many ways HIV and AIDS are not medical problems but political and economic ones. We need to fund sociological and ethnographic research into human sexual behaviour and mores. Our planning must look at the perspectives of teenagers and young adults now and also those who will be teenagers and young adults in 10 years time.

And we need to look after the 13 year old girl, whose parents have both died of AIDS and is now the head of the household, as described in the South African poet Ingrid de Kok’s poem. Her “children are many . . . she carries them under her arms / and on her back / though some must walk beside her / . . . homeless, motherless / . . . house balanced on her head.”


Cite this as: BMJ 2013;346:f2517


  • Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.

  • Patient consent not required (patient anonymised, dead, or hypothetical).

  • Provenance and peer review: Not commissioned; not externally peer reviewed.