The core group were the sex workers of Addis Ababa and other major towns, together with their habitual clients. Founded in 1886 on the model of a military camp, the capital was a sprawling jumble of permanent buildings and the squatter shacks in which over four-fifths of its nearly two million people lived. Women were a majority of the population, especially in the younger age ranges, for Ethiopian women married very young, divorce was common, and there was little place for unmarried women in the countryside. In the town, such women survived chiefly by informal activities, of which commercial sex was one of the most important. In 1973–4 an Ethiopian sociologist reckoned that some 27,000 women worked in bars, the chief meeting places for the city’s men. An official survey in 1982 identified 15,900 full-time sex workers in the city. A less official one, seven years later, estimated 24,825, excluding streetwalkers and women working from their own rooms, adding that 55 per cent had only one or fewer partners per week.62 Divorce, disagreement with parents, and lack of money to continue schooling were reasons often given for entering commercial sex. Major provincial towns had smaller but similar groups of sex workers.
Commercial sex had a role in Ethiopian urban culture similar to that in Kigali. Female virginity at marriage was vital to respectable families, if perhaps less so to their daughters than in the past, partly because marriage ages were rising with education. Men, by contrast, suffered little inhibition on sexual experimentation and on average (in 2000) married seven years later than their wives. Given this imbalance, as in Kigali, young men commonly had their first experience with sex workers and up to half continued to frequent them thereafter. Early in the epidemic most of these sexual encounters were unprotected, for Ethiopians were unfamiliar with condoms and hostile to them.63 Sexually transmitted diseases liable to facilitate HIV transmission were common, especially among sex workers. A study in Addis Ababa in the early 1990s found that only 9 per cent of women in their first marriage and 1 per cent of sex workers had no serological evidence of such a disease, while 33 per cent and 46 per cent, respectively, were infected with HSV-2, which caused genital ulcers and particular susceptibility to HIV. Moreover, Ethiopia’s health services were slender even by African standards, taking only 0.4 per cent of the national budget in 1999 and providing fewer than 20 per cent of pregnant women with antenatal care, as against an average of over 60 per cent in sub-Saharan Africa.64
HIV first became established in Addis Ababa among sex workers during an explosive epidemic in the late 1980s. In 1987, 5.9 per cent of them tested positive; by 1990 the figure had risen to 54.2 per cent. Prevalence was especially high in city centre brothels. By contrast, in 1989 only 4.6 per cent of the capital’s pregnant women were infected.65 Other places of very high prevalence among sex workers at this date were the trucking towns of Dessie, Nazareth, Mekele, Bahr-Dar, and Gonder on roads radiating outwards from Addis Ababa. In the far north, however, the disease was still rare, although it had penetrated to all parts of the country. Study of 23 towns in 1988 showed an average prevalence of 17 per cent among sex workers, 13 per cent among long-distance truck drivers, but only 3.7 per cent among blood donors (who broadly represented the general population).66 Among the latter, rapid epidemic growth began three or four years later than among sex workers, the annual incidence of new urban infections peaking in 1991 at about 2.7 per cent. Prevalence among antenatal women in Addis Ababa rose from 4.6 per cent in 1989 to 11.2 per cent in 1992–3, reaching its likely peak of 21.2 per cent in 1995.67
At the same time, the ratio of infected men to infected women in the capital fell from 3.7:1 in 1988 to 1.5:1 in 1994, suggesting that an epidemic that had begun among a core group had spread to the general population. In a study of 2,526 factory and estate workers in and around Addis Ababa in 1994, HIV infection in men was strongly associated with reported sexual behaviour and past history of syphilis, but in women it was associated with sociodemographic characteristics (low income, low education, and living alone) rather than sexual behaviour. Moreover, the burden fell increasingly on young women. In 1995, antenatal prevalence in Addis Ababa was 23.7 per cent among women aged 15–24, 17.7 per cent among those of 25–34, and 11.1 per cent among older women. In Dire Dawa, a railway town east of the capital, 57 per cent of all infected women in 1999 were aged 15–24.68
Ethiopia’s urban epidemic ceased to expand during the mid 1990s, although numerous new infections continued to compensate for the rising number of deaths. The missing element in the story, however, was expansion to the countryside, for the remarkable point about Ethiopia – in contrast, say, to Nyanza – was how little impact the disease had made in rural areas, where estimated adult prevalence was 0.3 per cent in 1990 and 0.8 per cent in 1995. This was partly misleading, for such was the predominance of the countryside in Ethiopia – 83 per cent of the population in 1999 – that rural infections overtook urban from 1997. Yet rural prevalence in 2000 was still only an estimated 1.9 per cent. It was highest in the central Amhara region, but in the remote Southern Nations Nationalities and Peoples Region, at that date, only 37 per cent of women had even heard of Aids, although the impact grew rapidly thereafter.69 Rural people, there and elsewhere, blamed townsmen and foreigners for the disease: ‘We Hamar don’t have cars with which to reach America. We don’t go to England, to gal [highland] country, to Germany, and going there, we don’t come back bringing illness. It comes to us by foot.’70
As in Rwanda and Burundi, it is difficult to explain the weakness of urban–rural transmission of HIV in Ethiopia during the 1990s. One element may have been the dispersed pattern of rural settlement that limited interaction. Studies of the extent to which farmers frequented sex workers in market towns found inexplicably varied proportions.71 As in Rwanda, occasional visits might do little to spread a virus so difficult to transmit, especially in a culture with near-universal male circumcision. The most detailed rural study, of a Muslim area in eastern Hararghe, concluded that it was protected from infection by its Muslim social order and its lack of exposure to high-prevalence urban groups.72 Perhaps this last point was the most important. The HIV/Aids epidemic throughout eastern Africa had been shaped by the network of communication provided by commercial economies. Vigorous around Lake Victoria and along the trans-African highway, they were less integrated in Rwanda and Burundi or the emptiness of central Tanzania. The particular weakness of its commercial economy had shaped much of Ethiopia’s modern history, notably its uncompleted revolution. Now the same circumstances helped to protect its countryside against infection.
5
The Conquest of the South
The countries of southern Africa, although infected with HIV slightly later than those further north, nevertheless overtook eastern Africa’s levels of prevalence during the mid 1990s and then experienced the world’s most terrible epidemic. By 2004 the region had 2 per cent of the world’s population and nearly 30 per cent of its HIV cases, with no evidence of overall decline in any national prevalence, which in several countries exceeded 30 per cent of the sexually active population. The chief issue in southern Africa is therefore to explain the speed and scale of epidemic growth. The obvious explanation is the region’s history of white domination and the dramatic economic change and social inequality it had wrought. The view here is that this is true, but the connections were not always obvious, while, as everywhere in Africa, the scale of the epidemic was chiefly due to the long incubation period that enabled it to spread silently beyond hope of rapid suppression.
By chance, both the earliest definite indication of HIV in southern Africa and the best evidence of the silent epidemic anywhere in the continent come from the remote rural Karonga district of northern Malawi, bordering Tanzania and Zambia. Karonga’s people, famed in colonial times for their education received from Scottish missionaries, had migrated as clerks and craftsmen throughout the industrial centres of southern Africa. This may first have exposed them to HIV. The virus’s arrival in Karonga can be traced because the district experienced a mass