In one sense, the fight against HIV sounds painfully simple: just get people to stop having unprotected sex.
Making this happen, though, is proving extremely complicated. From prostitution in informal settlements, to misleading statements by our leaders, and the dangerous consequences of men having multiple wives and lovers, the factors driving the sexual transmission of HIV are many and varied.
What there does seem to be consensus about, though, is that the job of HIV prevention is being botched. Indeed, reading Helen Epstein's new book The Invisible Cure, one gets a picture of huge amounts of money being spent badly.
Although Epstein's answers to the problem of prevention have been questioned by a number of experts, most seem to agree that efforts to contain the pandemic have been woefully inadequate.
Understanding the spread
The migrant labour system, for one thing, is thought to have played an important part – migrant labourers pick up the virus while working on the mines and then take it back to rural communities, transmitting it to their wives.
First, though, it helps to get some sense of the factors underpinning the spread of HIV. Why has sub-Saharan Africa in particular been so badly affected?
Epstein also argues that the practice of having long-term concurrent partners – tradition in some African societies, and famously practised by the man who is effectively president-elect, Jacob Zuma – is underestimated. Rather than prostitutes, she suggests, it is having multiple long-term partners that fuels the spread.
Epstein also pays a lot of attention to the shame often associated with HIV. She points to the reluctance in many communities to speak openly and frankly about the disease.
According to Nathan Geffen of the Treatment Action Campaign (TAC), this is in part because HIV is directly related to sex – how we have sex, how often, and with whom. "Most of us have been brought up to believe, if not intellectually then at least on an emotional level, that anything but heterosexual sex in marriage is wrong," he says, and "also, it's a potentially fatal, incurable disease."
It has also been suggested that President Mbeki's rejection of accepted HIV science was based on the misunderstanding that HIV was a disease of sexual depravity – exactly the kind of stigmatising view with which Epstein's book wrestles.
According to Geffen, stigma can be broken through processes like HIV treatment, literacy education, and simple things like getting people to wear "HIV positive" T-shirts. Public figures taking Aids tests are also seen as a useful tool.
"Stigma can be broken and usually is, especially if treatment is made available and HIV is no longer thought of as a death sentence," says Geffen.
Gregg Gonsalves of the Aids and Rights Alliance for Southern Africa strongly agrees with the link between the access to effective treatment and the breaking of stigma. "It is a human rights issue," he says. We should aim for a point where people say, "I deserve treatment. I'm worthy of not getting HIV."
He argues that reform is necessary on many levels to fight HIV/Aids, since the factors driving the pandemic are deeply rooted. There are reasons, he points out, that infection rates are so dramatically higher in informal settlements than in wealthy areas.
A risk worth taking
If people are in a position where behaviour change doesn't make sense, they won't change, he says, giving the example of a prostitute being paid double the usual rate if she forgoes condoms. If that extra money is going to make a significant difference to her, it's likely to be a risk worth taking.
Traditionally, public education interventions have been driven through psychological tools like counselling, billboards, and television advertisements. It may be time, Gonsalves says, to move toward larger public health interventions. We should start, he argues, by looking at the factors driving risk: sexual violence, rape, migrant labour, and poor housing, among others.
Seen in this light, interventions like judicial reform, police reform, and interventions in mining communities become key to the fight against HIV/Aids – as, indeed, does the general raising of living conditions in poor areas.
The tools we have
One of the biggest failures in the Department of Health's HIV prevention efforts has been the lack of attention given to the prevention of mother-to-child transmission of HIV (PMTCT), says Professor Nicoli Nattrass, director of the Aids and Society Research Unit at the University of Cape Town. "Anything short of 100 percent coverage is a failure."
The department has been widely criticised for delaying the introduction of new PMTCT guidelines and for its general lack of enthusiasm for implementing PMTCT programmes.
Getting that right, says Nattrass, would be key.
A second proven tool to reduce the transmission of HIV is circumcision. In 2007, following a series of studies which found that circumcision reduces a man's chances of contracting the virus by more than 50 percent, the World Health Organization recommended South Africa implement a large-scale circumcision programme.
Despite the evidence, Health Minister Manto Tshabalala-Msimang said her department believes the WHO's view to be "incorrect and misleading". Circumcision is a cultural practice, she said. This position contrasts poorly with the Kenyan response: the government there launched a widespread circumcision programme, paying particular attention to cultural considerations, and being very clear that though circumcision reduces risk, it doesn't eliminate it.
An 'African' response
The department of Health's rejection of circumcision as a preventative tool and its unwillingness to embrace PMTCT is possibly best seen in the wider context of its rejection of the accepted science on HIV/Aids.
This position has often been trumpeted under the banner of finding an "African" response to the problem of HIV. In South Africa, however, this approach has manifested in things like tolerance for people peddling unproven medicines and, most bizarrely, in the high-level involvement with the development of the now discredited drug Virodine.
In The Invisible Cure, Epstein outlines a very different "African" response to HIV/Aids. She describes how straight-talking information programmes in Uganda – she recounts a conversation about HIV with a cab driver – along with openness and willingness to use existing social structures, helped turn the tide of HIV in that country.
The ABC (abstain, be faithful, or use a condom) approach, along with the so-called zero-grazing programme (which encourage men to have fewer long-term partners and not to engage in casual sex) was also thought to be key. "Zero Grazing was a compromise. It recognised that sexual arrangements in Africa are often different from the Western nuclear ideal and serial monogamy," Epstein writes.
In fact, what exactly happened in Uganda remains disputed. "In my view (and others) the primary causes of the decline in HIV prevalence in Uganda were (1) overestimates of the prevalence by the UN in the first place, and (2) that deaths exceeded infections," says Geffen.
Whatever the case may be, it seems clear the Ugandan government's response to HIV/Aids was both more mature and more "African" than South Africa's.
- (Marcus Low, Health24, April 2008)
How things got so bad
HIV drug exploitation?