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But perhaps more than any other factor, effective prevention and treatment efforts directed at African-born residents have been hindered by the lingering perception that HIV remains a death sentence. People don't want to get tested, even if they suspect that they may be infected, because they don't believe anything can be done for them. In many ways the epidemic among African immigrants is reminiscent of the late '80s and early '90s, before the advent of antiretroviral drugs transformed HIV into a largely manageable disease. AIDS experts fear that African immigrants will suffer--and perhaps die--needlessly because of this lack of knowledge.
"There's no reason why they should die silent here," says Elizabeth Namarra, HIV/AIDS project consultant at the Minnesota Department of Health and a native of Ethiopia. "In Africa we understand [that] if they get tested positive, there's nothing they can do anyway. There's no treatment available. But here everything is available to them."
In 2003 the Somali Health Project, with the help of a grant from the Minnesota Department of Health, began conducting HIV-prevention workshops around the Twin Cities. The nonprofit group reached out to Somali enclaves in Eagan, Burnsville, Owatonna, and the Cedar-Riverside neighborhood of Minneapolis.
At the start of each workshop, participants were asked to fill out a survey to test their knowledge of HIV/AIDS. The results showed a disquieting ignorance about how the disease is transmitted. For example, 64 percent of workshop participants believed that HIV solely afflicts homosexuals, while some 81 percent thought that they could catch the disease by sharing a plate with someone who is infected. The respondents fared little better when asked about treatments. More than a third erroneously believed that there is a vaccine for HIV, while 38 percent indicated that vitamins could be taken to stave off infection.
"They thought that the disease was not for Muslims and not for Somalis," says Abdirizak Mohamed, executive director of the Somali Health Project. "People believe this disease is not for them. We have to convince them this disease is for everyone."
The questionnaire results indicate the acute need for effective HIV prevention efforts in African communities. "There are a lot of misconceptions," says Dr. Bosola Akinsete, a native of Nigeria who treats many HIV-infected African patients at Hennepin County Medical Center. "There's a lot of ignorance. We really need to conquer the misconceptions about the disease."
Part of the difficulty in providing effective prevention programs is that African immigrants are often resistant to even talking about the issue. Elizabeth Namarra, of the state health department, recalls that when she first began discussing the risks of HIV infection a few years ago, people weren't receptive. "I remember people getting up and leaving as soon as they heard the word "HIV" from my mouth," she says. "Some would say, 'This is not our concern. We don't have it in our community. We are religious. We don't have a problem.'" Namarra notes that initially more than half of the literature she passed out at community forums would be left behind on the floor.
Successful prevention efforts have also been stymied by the subordinate position that women often hold in African households. Many women who grew up in Africa didn't have access to higher education and remain financially dependent on their husbands. Too often women view themselves as powerless to refuse their husband's sexual demands. "There is a cultural norm where the African women have to be subordinate to their husbands," says Ephraim Olani, executive director of Sub-Saharan African Youth and Family Services, a St. Paul-based nonprofit group. "They don't have a right to negotiate about sex. They don't have the right to demand that the husband use a condom." Compounding the problem is the fact that polygamy is widely accepted in many African countries, therefore increasing the odds that an infected man will spread the disease to multiple women.
People who are already infected with the disease face even more daunting issues. HIV-positive African residents must deal with pervasive ostracism. It is not uncommon for people who test positive to be deserted by their spouses or kicked out of their homes.
As a result, people avoid getting tested in the first place. They'd rather live in ignorance than face the prospect of being rejected by friends and relatives. Unfortunately, such denial only exacerbates the problem by putting more people at risk of infection. It also makes it difficult to get an accurate gauge of how many African immigrants are HIV-positive.
"The only time people get tested is when they have symptoms, when they are very ill," says Dori Makundi, who works on issues affecting African immigrants at the Minnesota AIDS Project. "For sure there are a lot more people infected than have been tested."
As a result of this reluctance to be tested, many African-born residents don't receive any treatment until the disease has already wreaked havoc on their bodies. Dr. Akinsete, of HCMC, says that of 178 HIV-positive African immigrants treated at the hospital, 42 percent already had T-cell counts below 200--the generally accepted threshold for full-blown AIDS--when they were diagnosed.
Such patients can still be successfully treated with antiretroviral drugs, but in some cases their T-cell levels will never recover. This means that they will continue to have weakened immune systems and to be at high risk for opportunistic infections such as pneumonia and toxoplasmosis. "When you're less than 200, you're increasingly prone to those infections," explains Akinsete. "It's better not to have a low T-cell count."