Messages from years of AIDS campaigns are finally filtering down to the dingy streets of Johannesburg where sex workers turn tricks. But all of that can vanish in an instant when a customer offers a little more cash to have sex without a condom.
At least 5.6 million of South Africa's 50 million people are infected with HIV, but new studies show that here and elsewhere on the continent fear of the disease and knowledge about how to prevent it have begun to change sexual habits, and in some places dramatically reduce infection rates.
"If you don't take care of yourself, you're putting yourself at risk. If I get an infection, it will be my fault," said a sex worker who gave her name as Sarah.
Still, with around 14 million people receiving government assistance and a quarter of the workforce unemployed, there will be others who take the money - and the risk.
"There are some ladies who are forced to do it without a condom. If the client puts a certain amount on the table, some of them can't refuse it," said sex worker Dudzai.
East and Southern Africa are the areas most heavily affected by the HIV epidemic. Out of the total number of people worldwide in 2009 living with the human immunodeficiency virus (HIV) that causes Aids, 34% lived in 10 countries in Southern Africa, according to the UN Programme on HIV/Aids (UNAIDS).
Truckers spread HIV
Experts said one of the ways HIV spread through Southern Africa was via sex between long-haul truckers and prostitutes.
Recently, however, HIV new infection rates have been falling in the region and in sub-Saharan Africa. HIV incidence declined by 25% between 2001 and 2009.
"We're hoping that this 25% decline over the last 10 years will start to speed up," said Paul de Lay, deputy director of UNAIDS. "It's not happening fast enough. It's progress, but if it continues at this rate, we are talking about another 40 to 50 years of this epidemic until it gets down to the lowest levels."
The change in South Africa has been dramatic.
HIV does lead to Aids
A decade ago, the government was putting its faith in those who denied that HIV infection caused Aids, and funded traditional healers who proposed garlic and beetroot as cures while withholding proven drugs for treatment.
Now condoms are available for free at government offices, public awareness ads saturate TV airwaves and the state has allocated billions of dollars for treatment and prevention.
Trendy clubs have condoms in bathrooms and college students are well versed in safe sex, but there is always the risk that as the HIV problem begins to fade, fear of Aids will also subside and complacency could start to creep in.
"One of the biggest challenges we have with this epidemic is that without a vaccine or a cure, we need to keep the momentum of the prevention program going. They have to be constantly refreshed, because you have new cohorts of young people entering into risky behaviour every four or five years," said de Lay.
"Climate of fear"
In neighbouring Zimbabwe, researchers have found that fear of infection and mass social change have driven a huge decline in HIV rates.
In a study last month in the journal PLoS Medicine, British researchers said Zimbabwe's epidemic was one of the worst in the world until the rate of people with HIV almost halved, from 29% of the population in 1997 to 16% in 2007.
Simon Gregson of Imperial College London, an investigator on the study, told Reuters he thought there may be certain factors about Zimbabwe that might signal why the turnaround there has been so dramatic, and has come earlier than in other countries.
For a start, Zimbabwe had a major problem, so awareness of HIV and fear of Aids was acute.
A strong marriage system
"Zimbabwe is (also) distinctive in having high levels of education and quite a strong marriage system," he said. "It might be that messages that promote being faithful and sticking to one partner are more easily digested and translated into action in a country like Zimbabwe."
While campaigners applaud such success, their joy is tinged with uncertainty about how to maintain it.
De Lay points to places in the West like London and San Francisco, where high rates of HIV infection at the beginning of the epidemic in the late 1980s have faded into the background.
In a recent British TV programme where groups of teenagers were questioned about sexually transmitted diseases, none mentioned HIV. And a study from France last year found that among gay men, HIV rates are "out of control" despite an overall fall in the number of new HIV cases there.
Is scare-mongering healthy?
"What we are seeing... is a reduced sense of vulnerability, a reduced sense of how severe the disease is," de Lay said. And that opens up a dilemma about whether scare-mongering is healthy.
"We can't create a constant climate of fear, but at the same time people should have a healthy respect for how serious this is," said de Lay.
Further north on the African continent, in its most populous nation Nigeria, it appears that fatalism, not fear, rules.
In Lagos, traders in Obalende, a raucous market selling everything from bananas to motorcycles, said they had become more aware of the dangers of HIV in recent years. But this did not always affect their actions.
People are more aware
"People are getting more aware. They see things on TV and when they go to the hospitals," said Mohammed Babaji, a 42-year-old trader selling small braai kits.
Babaji said he tried to remain faithful to his wife, and that some of his fellow traders took their own clippers to the local barbershop to avoid possible contact with infected blood.
Yet an aversion to condoms persists.
"I know I am supposed to wear condoms to protect myself, but most young men here will not use them because they will not enjoy it as much," said Abdul Abdulkarim, 25 years old and single, as he touted leather sandals laid out on a plastic table.
"The men here have a lot of girlfriends and they use prostitutes. I don't think Nigerians really fear death." (Reuters Health/ March 2011)
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