Factors thought to influence this sexual transmission include 1 promiscuity, with a high prevalence of sexually transmitted disease; 2 sexual practices that have been associated with increased risk of transmission of AIDS virus homosexuality and anal intercourse ; and 3 cultural practices that are possibly connected with increased virus transmission female "circumcision" and infibulation. Other nonsexual cultural practices that do not fit the age distribution pattern of AIDS but may expose individuals to HIV include 1 practices resulting in exposure to blood medicinal bloodletting, rituals establishing "blood brotherhood," and possibly ritual and medicinal enemas ; 2 practices involving the use of shared instruments injection of medicines, ritual scarification, group circumcision, genital tatooing, and shaving of body hair ; and 3 contact with nonhuman primates.
At the current time promiscuity seems to be the most important cultural factor contributing to the transmission of HIV in Africa. The recent spread of AIDS throughout Africa raises the question of whether the mode of transmission of human immunodeficiency virus HIV in Africa is different from that in the United States and other Western countries. This report briefly examines cultural practices that may contribute to the spread of AIDS in Africa and highlights areas that require further research.
Any hypothesis that attempts to account for the equal sex distribution of AIDS cases in Africa must take into account the apparent age distribution of the disease. Cases are found in infants who presumably acquire the disease from their mothers and in sexually active adults. Although data for young children are still incomplete, AIDS cases have been reported only infrequently among those age groups, except in cases of blood transfusions.
Earlier reports of HIV seropositivity in children [ 5 ] may have been the result of nonspecific reactions [ 6 ]. Hence emphasis has been placed on sexual transmission of HIV. Factors thought to influence sexual transmission in Africa include 1 sexual promiscuity, with a high prevalence of sexually transmitted disease STD ; 2 sexual practices that have been associated with a high degree of transmission of HIV homosexuality and anal intercourse ; and 3 cultural practices that are possibly connected with increased virus transmission female "circumcision" and infibulation.
Other nonsexual cultural practices that do not fit the age distribution of AIDS but may expose individuals to HIV include 1 practices resulting in exposure to blood medicinal bloodletting, rituals establishing "blood brotherhood," and possibly ritual and medicinal enemas ; 2 practices involving the use of shared instruments injection of medicines, ritual scarification, group circumcision, genital tattooing, and shaving of body hair ; and contact with nonhuman primates.
Female circumcision and Infibulation It seems to be relatively difficult to pass HIV during normal vaginal intercourse. Thus, it has been proposed that heterosexual transmission is somehow enhanced in Africa.
Of course, even with a low rate of transmissibility, large numbers of sexual contacts will place a promiscuous individual at high risk for acquiring the infection. Enhanced heterosexual transmissibility may not required for explanation of the equal sex ration among AIDS cases in Africa if it is assumed that the virus originated and was spread in the promiscuous heterosexual population.
The same type of "epidemiologic accident" may account for HIV transmission in the promiscuous homosexual and drug addict populations in the West.
However, it has been proposed that heterosexual transmission is, in fact, enhanced in Africa because of the widespread practice of female circumcision [ 8,9 ]. Distribution of female excision hatched area and infibulation cross hatched area in Africa see [ 1 ] [ 4 ]. Female circumcision is a euphemism for female genital mutilation.
Although it is usually performed at or shortly before puberty in Africa, female circumcision has little relation to the practice of male circumcision and is not usually an initiation rite per se. Three types of female circumcision occur in Africa.
The most extreme, termed infibulation or pharaonic circumcision, involves partial closure of the vaginal orifice after excision of varying amount of tissue from the vulva, In its extreme form, all of the mons veneris, labia majora and minora, and clitoris are removed and the involved areas closed by means of sutures or thorns.
After the operation the thighs are strapped together for 4—8 weeks, with complete occlusion of the introitus being prevented by the insertion of a matchstick or other wooden object. A more moderate form of female circumcision is excision, which involves removal of the clitorus and part of the labia minora.
The mildest form, Sunna circumcision is circumferential excision of the clitoral prepuce [ 10 ]. Another practice that involves female genital mutilation is making "gishiri cuts," which are incisions on the vaginal wall and presumably serve the same purpose as female circumcision [ 11 ]. In may cases of infibulation and occasional cases of excision, the vaginal opening must be cut open by the husband defibulation in order for childbirth or in severe cases, sexual relations to occur.
After childbirth the woman is often sewn up again. In premodern times there were various "ritual" explanations for the practice of female circumcision. However, the practice continues in modern Christian and Muslim Africa. When it can be afforded, infibulation now is often performed in hospitals primarily in northwestern Africa [ 12 ] , so a "ritual" or "traditional" explanation for the practice seems less likely. One recent theory proposes that the practice is an effort by males and lineages to curtail female sexual pleasure and hence illicit sexual liasons, thereby increasing certainty regarding paternity [ 13 ].
In rural tribes where female circumcision occurs, it is nearly universal in the female population; however, its prevalence is decreasing in urban areas [ 11 ] Female circumcision has been postulated to increase the likelihood of AIDS transmission via increased exposure to blood in the vaginal canal [ 8 ].
The presumed explanation is that the small introitus, the presence of scar tissue which may cause tissue friability , and the abnormal anatomy of a mutilated vagina would predispose to numerous small or large tears in the mucosa during intercourse.
These tears would tend to make the squamous vaginal epithelium similar in permeability to the columnar mucosa of the rectum, with increased absorption of secretions and virus. A less likely explanation involves sexual intercourse shortly at or shortly after the time of female circumcision, when open wounds are present. Tentative distributions of areas with a high level of seropositivity for human immunodeficiency virus. There are several reasons why female circumcision may not be an adequate explanation for enhanced heterosexual AIDS transmission.
Although the presence of lesion in the vagina may increase male-to-female transmission, it is unclear how female-to-male transmission would be enhanced in this situation. A possible cofactor is untreated STD, which could result in the breakdown of the mucosal integrity of the male sex organs. The only area in Zaire that is affected is in the north. Although data are sketchy [ 10 , 11 , 14 ], female circumcision is not practiced in areas with the highest level of HIV seropositivity.
From evidence presently available, these areas of high seropositivity are eastern Zaire, Rwanda, Burundi, western Uganda, northwestern Tanzania, and northern Zambia [ 1 , 3 , 5 , ] figure 2. There is some overlap of areas in which excision is performed and areas with a lower degree of seropositivity, including parts of Zaire, Kenya, Central African Republic, and Tanzania.
It must be stressed that data are incomplete for these areas. Traditional anthropologists tend to pursue details of sexual practices in their studies, and various political upheavals have made work in the regions involved difficult in recent times. There is also a definite problem in data collection by foreigners especially male foreigners on this topic. It is possible that population movements have introduced the practice of female circumcision into urban areas where it was previously not found.
In fact, it is not clear that increasing westernization and urbanization have reduced the practice of female circumcision. For example, except for the Luo, the practice is still widespread in urban areas of Kenya. This pattern may begin to change now that President Arap Moi has spoken against the practice; in contrast former President Jomo Kenyatta felt that excision was a traditional part of Kikuyu life [ 33 ].
Questions relating to female circumcision that require further research include the following: Needless to say, the study of many of those issues would be extremely difficult from both technical and political standpoints.
Although generalizations are difficult, most traditional African societies are promiscuous by Western standards. Promiscuity occurs both premaritally and postmaritally.
For instance in the Lese of Zaire, there is a period following puberty and before marriage when sexual relations between young men and a number of eligible women are virtually sanctioned by society. The father of a woman may judge the suitability of the man on the basis of the perceived willingness to invest in his daughter [ 36 ]. In the so-called "matrilineal belt" centered in south-central Africa, there is an especially high degree of adolescent promiscuity and uncertainty about paternity.
This situation has probably contributed to the prominent family role of the mother's brother. For example family wealth is inherited by offspringe of the maternal uncle rather than by patrilineal descendents from the husband. That is, wealth is passed on to a known biologic relative, rather than to the offspring of a wife who may or may not be biologic kin. Matrilineal inheritance thus may reduce societal pressure to prevent promiscuity; matrilineal societies are often promiscuous societies [ 37 ].
However, promiscuity is correlated not only with matrilineal societies. Many patrilineal African societies are promiscuous as well. The distribution of infertility is patchy in affected areas. Regions of low fertility border on areas of high fertility.
For example in two neighboring districts in the Sudan, the local infertility rates vary from 3. This primary sterility is thought to be due to high levels of STDs that result in pelvic inflammatory disease in young women [ 39 ]; transmission of STDs is presumably enhanced by promiscuity.
It is of interest that the "infertility belt" is in areas with a high prevalence of antibody to AIDS virus, which also may be related to promiscuity. As people leave rural villages and migrate to urban areas, the general level of promiscuity usually increases. This increase may be attributable in part to the relaxation of traditional village values but appears to be due primarily to the destitution of poor migrant women, who may become prostitutes, and to the greater mobility and rootlessness of young male migrants and soldiers.
Unlike some Asian societies, traditional African societies have no apparent pattern of ritual prostitution, and it is unlikely that women who become prostitutes for purely monetary reasons would be tolerated in traditional surroundings.
Increased prosmiscuity is especially common among upper- and middle-class urban men, who can afford the services of prostitutes. As has been noted previously, levels of STDs are generally high in Africa [ 4 ]; this fact may reflect both casual attitudes toward sex and high levels of promiscuity as well as the lack of easily available treatment. Schuster [ 42 ] provides an in-depth treatment of the lives of Zambian career women who preceive themselves as better off trading sex for favors and expensive gifts than marrying; contemporary urban life provides wives with little of the traditional support systems of the village, and the lives of married women are isolated, bleak, and improvished [ 41 ] It is perhaps significant that the first cases of AIDS in Central Africa were reported by in upper class Zaireans seeking medical treatment in Europe [ 14 ].
Except for a few rural areas e. However, not enough data are available on either the presence of AIDS in rural areas or sexual patterns of urban and rural areas for the establishment of definite correlations. Population movements in Africa contribute to the "sexual mixing" of various African groups and may be related to the spread of AIDS. The entire Central African area and indeed the whole of sub-Saharan Africa is experiencing large shifts in population.
Some patterns have existed for long periods, such as the movement of Arabic and Nilotic peoples into the northern part of Central Africa [ 44 ]. The long-term movement of rural population into urban areas is also continuing.
Other more recent trends include the movement of migrant workers from Zaire and Rwanda to neighboring countries e. It is probably significant that AIDS cases seem to have been present in Africa only since the s [ 15 , 45 , 46 ]--a time frame that correlates with the intensification of urbanization and population shifts.
The relative efficiencies of HIV transmission from male to female and from female to male are still unclear. If these efficiencies are equal and prostitutes represented the major reservoir of HIV infection, a higher male-to-female ratio of cases would be expected since each prostitute has many sexual contacts. However, it is unlikely that female promiscuity is confined to "professional" prostitutes, especially in urban areas [ 42 ].
It is also possible that the male-to-female transmissibility of HIV is higher than female-to-male transmissibility, presumably because of the higher concentration of HIV in semen than in cervical secretions [ 47 ]. Both of these factors would tend to produce a more equal sex ratio among cases of HIV infection. Data from a high-infertility area of Uganda indicate that the rate of carriage of gonorrhea is 8. These values are in contrast to the corresponding carriage rates of 4.
Hence gonorrhea rates in this high-infertility region tend to be at least as high in women as in men. Of course, data on gonorrhea and other STDs are not strictly relevant to HIV infection since classical STDs can be successfully treated and are more often asymptomatic in women than in men. Although the link between the risk of acquiring AIDS and promiscuity seems to be clear at this time, there are some unanswered questions: Homosexuality and Anal Intercourse Homosexuality is not a part of traditional societies in Sub-Saharan Africa [ 44 , 49 ].
The few instances of homosexuality noted are related to societal institutions where an older man has authority over younger males.
In the Bwamba of Central Africa, a male teacher of some young boys was reported to have exposed his penis and then asked the boys to "blow it like a whistle" [ 50 ]. Homosexuality probably also exists to some extent in migrant labor camps, where few women are present.
These anecdotal accounts do not indicate widespread homosexuality like that which seems to occur in some societies.