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AIDS in South Africa: The Invisible Cure

1.

HIV infection rates in South Africa’s townships are among the highest in the world. Hundreds of people contract HIV every day in South Africa, most of them in the poor, often dangerous township communities of crowded tin and concrete shacks. By now, nearly everyone in South Africa knows how HIV is transmitted, and how to avoid it. The enduring mystery is why so many people do not.

Of the roughly half-million South Africans who become newly infected with HIV each year, around half are under age twenty-five. In 1996, anti-retroviral drug cocktails were shown to be effective in treating AIDS symptoms, but these drugs alone cannot resolve the AIDS crisis in South Africa. They are not a cure, they don’t work for everyone, and they are expensive. Few South Africans can afford them, and the South African government, cruelly in the view of many, is only now considering whether or not to offer these drugs to South Africans with AIDS, including the poor. Also, these drugs do not prevent HIV from spreading. Public health campaigns to encourage young people in particular to avoid sex, or at least have fewer sexual partners, or use condoms if all else fails, remain vitally important.

However, to date, many HIV prevention programs in Africa have proven surprisingly unsuccessful. For example, during the 1990s, an ambitious HIV prevention campaign carried out in a South African gold-mining community was held up as a model for the rest of Africa. Health workers raised awareness about HIV using community meetings, drama, and music; condoms were liberally distributed in public places; and treatment services for sexually transmitted diseases such as syphilis, which make it easier for HIV to spread, were greatly improved. But this campaign had no measurable effect on HIV transmission rates. In Uganda, where HIV rates declined in the 1990s, a recent study indicated that this decline was probably not attributable to either the improvement of treatment services for sexually transmitted diseases or a program to encourage safer sexual behavior, including condom use. HIV rates have continued to rise in even those sub-Saharan African countries where the use of condoms has been aggressively promoted in the press and radio and services for treating sexually transmitted diseases have been improved.1

Why haven’t these programs been more successful?2 Many public health experts have tended to regard HIV prevention in Africa as merely a technical problem. But perhaps this view is inadequate. Perhaps in addition to condoms, syphilis treatment kits, sex education modules, and warnings on billboards, something else is required: some shift within the minds of individual people and in the social atmosphere so that AIDS is recognized as the immediate threat that it is.

The one African region that has seen a significant and sustained decline in HIV rates is an arc of territory north and west of Lake Victoria, including most of Uganda and the adjacent Kagera region of Tanzania, where HIV rates fell from around 18 percent in the early 1990s to around 6 percent today. It is becoming increasingly clear that HIV transmission in this region began to decline in the late 1980s, before any of the activities I have mentioned got seriously underway.3 Uganda’s success in combating HIV is generally believed to have been accompanied by powerful social activism, which swept the country in the aftermath of the civil war in the early 1980s. The enlightened policies of Yoweri Museveni’s government, which came to power in 1986, contributed to this movement, including its support for HIV prevention programs in the Ministry of Health, and later in other ministries as well, its supportive attitude toward community-based AIDS organizations, its success in restoring the economy, and its support for greater press freedom, as well as Museveni’s own willingness to openly discuss the epidemic in public.4 But also important was an unusually active response to AIDS on the part of ordinary people.

By 1997, more than one thousand Ugandan nongovernmental organizations were caring for people with AIDS and their families and also raising awareness about the risks of HIV infection. Medically, there wasn’t much these organizations could do for people with AIDS, since Uganda’s health care system was destroyed during the war and drugs to effectively treat AIDS were not widely available. However, their activities, mainly feeding and nurs- ing the patients and their families, gave patients some dignity and brought into the open the tragedy of AIDS. Some of these organizations also conducted village meetings, rallies, and drama and musical performances that encouraged people to avoid HIV by remaining faithful to a single sexual partner, or by using condoms. What made many of these events particularly powerful was that the speakers and performers often dealt openly with the effect of AIDS in their own lives. These organizations were established not by the Ugandan government or by foreign agencies, but by individuals who had watched friends and family members die.5 Their commitment, and their success, have their roots not only in fear for others and for themselves, but in compassion for the suffering they have witnessed.

Uganda’s success has been hard to repeat in other countries, including South Africa. Part of the problem lies with the South African government’s adversarial relationships with many nongovernmental organizations. In developing the country’s AIDS policies, the Health Ministry has largely ignored the nation’s many AIDS activists and health workers, and has sometimes aggressively disparaged them. A spokesman from the ANC Youth League recently attacked activists who have protested the government’s unwillingness to provide antiretroviral drugs for poor South Africans, calling them “paid marketing agents for toxic AIDS drugs from America.” President Thabo Mbeki has questioned whether HIV really is the cause of AIDS and has entertained theories—dismissed by most scientists—that the disease might also be caused by poor nutrition, unsanitary conditions, and even the very drugs that have been developed to treat the disease. Meanwhile, Mbeki’s minister of health recommended garlic for the treatment of AIDS, and an official in the Department of Housing accused journalists who defended the AIDS activists of fanaticism, and quoted Lenin on how the “press in bourgeois society…deceive[s], corrupt[s] and fool[s] the exploited and oppressed mass of the people, the poor.” The activist groups, meanwhile, have accused the health minister of “murder” for denying millions of South Africans access to medicine for AIDS.6

The strained relationship between the South African government and non-governmental organizations has almost certainly undermined efforts to prevent the spread of HIV. In 1998, a group of public health experts from South Africa and the US who were concerned about the worsening crisis decided that South Africa needed a bold new HIV prevention program for young people. They also knew they had to take account of the South African government’s attitudes toward AIDS. Their program, called loveLife, is now South Africa’s largest and most ambitious HIV prevention campaign. It both aims to overcome the limitations of similar campaigns that have failed in the past and, at the same time, it avoids dealing with the issues of treatment and care that have become so controversial in South Africa.

Can this work? Is it possible to prevent the spread of HIV without addressing the needs of HIV-positive people? Epidemiologists will not know for years whether loveLife has any effect on HIV transmission rates. In fact, they may never know, because young South Africans are increasingly exposed to many other HIV prevention programs, and the influences governing sexual behavior are not easy to disentangle in any case. However, loveLife has been endorsed at one time or another by the head of the United Nations AIDS program, the archbishop of Cape Town, Nelson Mandela, Jimmy Carter, Bill Clinton, the king of the Zulu tribe, and even Jacob Zuma, South Africa’s deputy president, and Zanelle Mbeki, the wife of the President. LoveLife’s budget is $20 million a year and it has received large donations from the South African government, UNICEF, the Bill and Melinda Gates Foundation, and the Global Fund to Fight AIDS, Tuberculosis and Malaria, the Swiss-based organization conceived by UN Secretary General Kofi Annan to raise money for health programs in developing countries. For years, these donors, along with the governments of the US, Great Britain, and other developed nations, paid scant attention to the AIDS epidemic in Africa. Now that funding is finally available, it is worth asking how it is being spent.

2.

I met loveLife’s director, David Harrison, an enthusiastic, committed white South African doctor, in Johannesburg in February 2003. “What we want to do is create a substantive, normative shift in the way young people behave,” he explained to me. The average age at which young South Africans lose their virginity—around age seventeen—is not much different from the age at which teenagers in other countries do. What’s different, says Harrison, is that many of the young South Africans who are sexually active are very sexually active. They are more likely to start having sex when they are very young, even below the age of fourteen. They are more likely to have more than one sexual partner and they are less likely to use condoms. South African girls are more likely to face sexual coercion or rape, or to exchange sex for money or gifts, all of which place them at greater risk of HIV infection. For Harrison, the trick is to “get inside the head-space of young people…we have to understand what is driving them into sex—they know what HIV is, but they don’t internalize it,” he said.

In order to do so, he claims, they have to learn to speak openly about sex and about the risk of HIV infection. Behavior change to avoid HIV infection is not a passive process, he explained. Young people must talk to each other and to their parents to really understand and internalize what they know. According to Harrison, traditional HIV prevention campaigns are too depressing, they try to scare people into changing their behavior, and this turns kids off. LoveLife’s media campaign, on the other hand, is positive and cheerful, and resembles the bright, persuasive modern ad campaigns that many South African kids are very much attracted to.

LoveLife’s most immediately recognizable presence is its billboards, of which there are more than a thousand in South Africa. They loom over nearly every major road, and they are striking. For example, on one of them, the hands of four women of different races caress the sculpted back and buttocks of a young black man as though they were appraising an antique newel post. The caption reads, “Everyone he’s slept with, is sleeping with you.” On another, a gorgeous mixed race couple—the boy looks like Brad Pitt, the girl like an Indian film star—lie in bed, under the caption “No Pressure.” Some people told me they found these ads disturbing, but it is hard to see why. On the same roads, there are torsos advertising sexy underwear and half-naked actresses advertising romantic movies; sex is a potent theme in marketing all sorts of products. LoveLife, according to its creators, tries to turn that message around to get young people thinking and talking about sex in ways that will convince them of the virtues of abstinence, fidelity, and the use of condoms.

  1. 1

    Anatoli Kamali et al., “Syndromic Management of Sexually-Transmitted Infections and Behaviour Change Interventions on Transmission of HIV-1 in Rural Uganda: A Community Randomised Trial,” The Lancet, Vol. 361 (February 22, 2003), pp. 645–652; Denise Gilgen et al., “The Natural History of HIV/AIDS in South Africa: A Biomedical and Social Survey in Carletonville” (Johannesburg: CSIR, 2000).

  2. 2

    For a review of the technical approach to HIV prevention, see John Stover, Neff Walker, Geoff P. Garnett, et al., “Can We Reverse the HIV/AIDS Pandemic with an Expanded Response?” The Lancet, Vol. 360 (July 6, 2002), pp. 73–77. For a critique of the tech-nical approach to HIV prevention see Edward C. Green, prepared witness testimony, Committee on Energy and Commerce, Subcommittee on Health, March 20, 2003, at energyvcommerce.house.gov/108/hearings/03202003 /hearing 832/green1379.htm.

  3. 3

    HIV transmission,” or the frequency with which new infections occur, differs from “the HIV rate,” which is the percentage of infected people in a population at a particular time. In Uganda, HIV transmission declined several years before the HIV rate declined.

  4. 4

    Museveni’s tolerance for Uganda’s active civil society has recently been questioned. See “Uganda Attacks Freedom of the Press,” Human Rights Watch press release, October 11, 2002.

  5. 5

    See Open Secret: People Facing Up to HIV and AIDS in Uganda (Strategies for Hope, 2000). Some organizations did receive foreign aid, once established.

  6. 6

    Helen Schneider, “On the Fault-Line: The Politics of AIDS Policy in Contemporary South Africa,” African Studies, Vol. 61 (2002), pp. 145–167; Samantha Power, “The AIDS Rebel,” The New Yorker, May 19, 2003, pp. 54–67.

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