The author is currently on an internship in Johannesburg, South Africa, as part of Medill’s Journalism Residency program.
Johannesburg, South Africa — In the United States, MTV still pays lip service to HIV prevention. But for most of MTV’s target audience, HIV/AIDS awareness has all but fallen off the radar. At Northwestern University, students are more likely to have lost a friend to drunk driving than to AIDS.
Compare that same age group to their peers in South Africa, where 45 percent of youth aged 15 to 24 know someone who has died of AIDS.
The disease has ravaged South Africa — by some estimates, it causes half of all deaths in the country — and the nation now has one of the highest HIV rates in the world: nearly one in five adults have the virus. By proportion, that’d be as if every adult in the states of California and New York was infected.
As the most severe case of a global epidemic, South Africa is a medical battleground that has resisted efforts from the world’s wealthiest nations and brightest researchers. Through federal aid and private grants, America has poured billions into the country and the rest of sub-Saharan Africa.
Treatment and prevention programs across the continent receive aid through the Bush administration’s President’s Emergency Plan for AIDS Relief (PEPFAR), a $15-billion, five-year plan that has garnered widespread praise for its commitment to stopping HIV/AIDS. Congress this month argues about whether to expend an additional $50 billion to fight the sexually transmitted disease, reviving a cultural debate that pits pro-abstinence conservatives against liberals who argue for more condoms and better sex education.
But what’s alarming is that no matter what Americans choose, the programs they pay for haven’t made much of a difference. Researchers point to studies that suggest Americans’ cultural blinders keep us from accepting how the sexually transmitted virus spreads and realistic ways it can be stopped. As a result, they argue, ineffective organizations end up getting massive support.
And so the lives of tens of millions may hinge on whether Americans can shed their preconceptions about sex — and focus their energies on proven solutions to the HIV/AIDS crisis.
The American HIV/AIDS rate peaked at around one percent in 1995. It hit certain demographics hard: gay men and intravenous drug users. In South Africa, which has the highest HIV rate in the world, about 18 percent of adults aged 15 to 49 are infected, most of them heterosexual, non-drug users.
To the average American, the differences seem easy to explain. South Africans don’t have enough access to condoms. They don’t understand how HIV is transmitted, or they believe in urban legends – that sex with a virgin cures HIV, for example.
“There’s a great presumption that Africans are ignorant. It’s not correct,” says Adam Ashforth, a Northwestern University professor of African Studies who spent several years in the 1990s researching in Soweto, a township in Johannesburg. “Basic knowledge about HIV has been extremely widespread. Ordinary people have known the correct answer [to] ‘How do you [get] AIDS?’ for a long time.”
Population surveys back up Ashforth: The majority of South Africans knows how HIV spreads and can be prevented. Sexual education can be improved, but it isn’t the problem.
In the late 1980s, researchers had another theory: Africans had more casual sex. To many Americans, this idea made sense — HIV is sexually transmitted, and because rates of infection were higher in sub-Saharan Africa than anywhere else in the world, Africans must have more sex with more partners.
But to Africans, this theory smacked of racism. The current president of South Africa, Thabo Mbeki, was especially furious about the assumption that Africans were sex-crazed. In a 2001 speech to South African university students, Mbeki angrily rejected the idea that Africans were “natural-born, promiscuous carriers of germs” and the notion that the continent was “doomed to an inevitable mortal end because of our unconquerable devotion to the sin of lust.”
Mbeki’s disgust may have influenced his current views on HIV/AIDS. The University of Sussex graduate and economist has since become famous for questioning the connection between HIV and AIDS. He has drawn international criticism for suggesting that AIDS-related diseases are caused by poverty and nutritional factors.
Mbeki has also dismissed antiretroviral drugs, which can add years to the life of an HIV-infected person, as a conspiracy to feed toxic poison to Africans. He has been accused of delaying the roll out of such medicine, and has appointed a Minister of Health who encourages HIV-positive people to eat beetroot and garlic as treatment.
Mbeki is right on one thing, however: Africans don’t contract HIV at a rapid rate because of uncontrollable sexual appetites. In fact, South Africans have about the same average number of sexual partners in their lifetimes as Americans. People in both countries also have sex for the first time at about the same age.
“There is an assumption that Africans are promiscuous,” says Dr. Edward Green, a senior researcher at Harvard University’s Center for Population and Development Studies who investigates the HIV/AIDS pandemic in sub-Saharan Africa. “That is at odds with our best behavioral surveys. Mbeki doesn’t like the reinforcement of the oversexed African, and I agree with him on that.”
A young man with dreadlocks plays a trumpet alone in a room. A sound outside disrupts his practicing and when he goes to look, he finds a large, colorful parade in the street. He joins the festivities, playing his trumpet as he marches. The music swells as the slogan, written in youthful text-speak, flashes across the screen: “The loveLife generation — will U b part of it?”
This is one of the recent broadcasting campaigns of loveLife, a South African HIV/AIDS prevention program. LoveLife began in 1999 and is backed by millions of dollars from U.S. foundations as well as the South African government. Aimed at teens aged 12 to 17, it’s one of the largest media efforts targeting HIV prevention in youth, and one of the most controversial.
Critics claim the program aims to please American sensibilities. Supporters argue that the program is both effective and important. Refilwe Africa, 30, the media director of loveLife, says she was “hooked” by the program’s message when she joined the company five years ago. In a phone interview, she enthusiastically explains why loveLife works.
“A young person who is confident,” she says, “is less likely to engage in risky behavior.” This idea of empowerment drives loveLife’s message. The program uses flashy media campaigns to encourage students to delay sex, but doesn’t preach abstinence. Several commercials focus on youth who’ve turned their lives around after teen pregnancy and involvement in gangs. LoveLife radio programs, broadcast in all 11 of South Africa’s official languages, encourage young people to take responsibility for their own health. Billboards around the country urge teens to “Make Your Move,” loveLife’s most recent empowerment message.
Refilwe argues that youth need to feel empowered just as much as they need to understand why safe sex is important. “How many times can you say to a person, you need to use condoms before they get bored?”
LoveLife’s most important work happens “face-to-face” in its youth centers, she says, where teens can participate in sports activities and computer classes. Young people aged 18 to 25 volunteer to be “groundBREAKERS” and run programs, spreading the message of HIV prevention to people a few years younger than them. LoveLife also partners with public health centers, operates a national telephone support line and publishes a magazine.
Research shows that a non-moralizing approach works, according to loveLife CEO David Harrison. He points to a 2003 study by the University of Witwatersrand in Johannesburg that showed that youth who participate in loveLife programs are less likely to have HIV.
But some say that studies like that are flawed because they are based on a self-selected group that is already at less at-risk for HIV infection.
“In some instances, they have claimed impacts on the basis of poor science,” wrote Dr. Warren Parker of the South African-based Centre for AIDS Development, Research, and Evaluation (CADRE) in an e-mail. “Unfortunately, these claims were used to leverage large amounts of funding.”
Other critics argue that loveLife ultimately glamorizes sex. “The focus of loveLife, whatever their pamphlets might say, whatever they might say when asked — most of their efforts went into promoting condoms and feeling good about sex,” says Harvard researcher Dr. Green. “I’m all for guilt-free sex. But that was not the message that South Africa needed.”
LoveLife is currently funded primarily by the South African government and by the Henry J. Kaiser Family Foundation, a California-based non-profit organization. Controversy has cost the program other funding in recent years: The Global Fund to fight AIDS, Tuberculosis and Malaria withdrew its grant in 2005, explaining that loveLife had not “sufficiently addressed weaknesses” in its prevention strategies.
“Three years down the line, my first response is still that it’s an absolute tragedy,” Harrison says about loss of the grant. “No other youth program has been so rigorously evaluated in the world. I’m afraid there [were] other things going on there. There was huge pressure from [conservative] Americans that loveLife didn’t get any further funding.”
So the problem behind the HIV pandemic is not education. It’s not promiscuity. What about condoms?
“Condoms have simply not worked in Africa,” Dr. Green says. “No country has been able to achieve high rates of condom use.”
About 90 percent of South Africans have easy access to condoms. But only half of South African youth reported using a condom the last time they had sex. According to Green, it’s easy to point the finger at South Africa for lack of condom use until Americans look at their own numbers: A 1995 study showed that only about two-thirds of American teenagers used a condom the last time they had sex.
As it turns out, Americans have more in common with South Africans than they think. Citizens in both countries have similar profiles in terms of knowledge about HIV transmission, number of sexual partners, and condom use. Why, then, is the HIV epidemic in South Africa getting worse while the epidemic in the United States is drawing to a close?
In her book The Invisible Cure, Helen Epstein writes that the chances of getting HIV during unprotected vaginal sex in a one-time sexual encounter with an HIV-positive person are around one percent — higher if the infected person recently contracted the virus. If that single encounter evolves into a relationship, the person infected with HIV only has an 8 percent chance of passing it on to their partner over the course of one year.
Simply put, HIV is a difficult virus to transmit.
According to Epstein, sub-Saharan Africa’s soaring HIV rates are are the result of an often-ignored sex practice – people having multiple long-term relationships at the same time. In parts of Africa, such as Uganda, around 40 percent of men and 30 percent of women report relationships that overlap for months or even years. In the U.S., Epstein argues, people are more likely to stick to one partner at a time.
“If an American contracts HIV from a boyfriend, she probably won’t pass it on to anyone else until the couple breaks up,” Epstein writes in her book.
“If a man with two long term partners contracts HIV,” she continues, “he will very likely pass the virus on to both of his partners in a very short time. If either of his partners has another partner, these ‘partners of his partners’ will very soon become infected too.”
Epstein uses Uganda as the example for her theory because it is the only African country to have seriously reduced its HIV rate. In the early 1990s, HIV rates peaked in Uganda at about 15 percent and then began to fall. Between 1991 and 1998, prevalence dropped by half.
Suddenly, everybody wanted to know what was happening in Uganda. If the reasons behind its falling HIV rate could be found, researchers argued, they could be applied to the rest of Africa and the epidemic could be stopped.
The problem was that nobody seemed to agree on what those reasons were. Some studies showed the decline came from condom use. But according to Epstein, condoms were difficult to get in Uganda until the middle of the 1990s, and condom advertising was banned by the government in 1994.
“As researchers start to pick through the reasons for this success, one troublesome fact emerges: condoms had little to do with it,” wrote Suzanne Leclerc-Madlala, an anthropology professor at the University of KwaZulu-Natal, in a South African newspaper in 2002. “Ugandan men never really took to condoms.”
Others, including former University of Cambridge researchers Dr. Rand Stoneburner and Dr. Daniel Low-Beer, say the key in Uganda was partner reduction. Epstein points to the Ugandan HIV prevention program Zero Grazing, which urged people to stick to one partner.
But even if Epstein, Stoneburner and Low-Beer are right about partner reduction and HIV prevention in Uganda, the question remains: Would it work in South Africa as well?
“I know more people [in South Africa] who are involved in concurrent relationships than not,” wrote David Patient, an HIV/AIDS activist that has lived in both South Africa and the U.S. and has been HIV-positive since 1983, in an e-mail. “It’s a way of life here. It’s like the old polygamy lifestyle of yesteryear has been ‘upgraded’ to reflect current socio-economic realities.”
The “polygamy lifestyle” that Patient refers to is still a reality in modern-day South Africa. Polygamy is legal and Zulus, South Africa’s largest ethnic group, traditionally practice it. Jacob Zuma, president of South Africa’s largest political party, the African National Congress, is Zulu and has at least three wives. He is also currently in position to become the next president of South Africa.
Workers migrating from rural areas to city centers might also encourage multiple partnerships and the spread of HIV. Many young men are forced to leave their rural homes in search of work, and end up in mines and factories in large cities such as Johannesburg. They can only return home to their families, and wives, a few times a year. Taking on other partners in the city is common.
“When the U.S. got involved in prevention [in sub-Saharan Africa], I was trying to advocate early on that they would seize upon what was happening in Uganda,” says Stoneburner, who worked for the World Health Organization in the 1990s and is now an independent researcher. “This was in 1996, 1997, and you just couldn’t get anybody interested in [partner reduction]. I was just flabbergasted by it all…[Americans] were terrified almost of hearing that it didn’t appear to be condoms in Uganda. They just literally shut down and sort of denied it.”
According to Stoneburner, American foundations poured money into promoting condom use and HIV education in sub-Saharan Africa in the 1990s. The idea that faithfulness, rather than condom use, prevented transmission was not a popular explanation for Uganda’s changing HIV rate.
The denial stems from “fears of preaching morality and identifying with the faith-based sector” according to Leclerc-Madlala.
Susan Watkins, a sociology professor at the University of Pennsylvania who has studied the HIV epidemic in rural Malawi, says that promoting safe sex was the only politically correct HIV prevention plan in the 1990s.
“[Condom promotion] seemed to be consistent with reproductive rights,” she says. “You know, we don’t tell people what to do.”
This 90s consensus — don’t moralize, promote condoms — seems to have held strong in the United States until the political tide began to turn. When George W. Bush was elected president in 2000, abstinence sex education gained massive government support both at home and abroad.
“When some of the Ugandan data came out, [conservatives were excited] that it was personal behavior,” Stoneburner says. “It would sort of promote their moral beliefs of how people should behave.”
In sub-Saharan Africa, the Bush administration quickly latched onto what has been coined the ABC approach – abstain, be faithful, use condoms – that seemed to be the answer in Uganda. The problem with ABC, critics claim, is that there’s too much focus on abstinence.
Bush’s PEPFAR allocates one-third of its prevention funding for abstinence-until-marriage programs. PEPFAR has been criticized in the press for promoting “neo-colonialism” and the President’s own religious views.
On April 2, PEPFAR was reapproved by the House of Representatives and its funding increased to $50 billion. But this time around, the abstinence clause has been removed, much to the chagrin of conservative politicians. The bill still needs to be approved by the Senate.
Political bent is a huge factor in international aid, Watkins says. And the debate in Congress over which approach to HIV prevention in sub-Saharan Africa is better — sex education or abstinence — tends to leave partner reduction out in the cold. American aid organizations of all political and religious stripes fund programs which endorse their views, often polarizing HIV prevention into two camps. The “be faithful” message has become the lost middle child in the “ABC” spectrum.
What does the CEO of one of South Africa’s largest prevention programs think about the theory of partner reduction in Uganda?
“Nobody knows what happened in Uganda,” Harrison says. “Nobody knows what caused the decline. Various interpretations have been attributed to it.”
But Epstein maintains that the data points to partner reduction. “It’s very clear what happened in Uganda,” she says in a phone interview. “Anybody who tells you otherwise is trying to protect a large number of careers.”
Harrison refers to the concurrent partners theory in an e-mail as “the flavour of the month” and says that focusing on it “doesn’t really change the decades-old instruction of ‘faithfulness’ in partnerships.” According to Harrison, the problem isn’t the lack of focus on partner reduction in South Africa, but the fact that nobody’s listening.
But Dr. Green says that loveLife’s pro-sexuality message doesn’t put enough focus on abstinence or partner reduction.
“I’m not a prude,” he says. “But I think we should be putting money into things that work and save lives.”
Harrison maintains that the loveLife approach is part of a broader solution, one that includes abstinence, partner reduction, condoms and empowerment.
“There is still an overwhelming HIV epidemic, so quite clearly none of us has found the Holy Grail,” he wrote in an e-mail. “Unfortunately, given the ideologically polarizing nature of sex (and the desire for proprietary ownership of ideas by the big funders), it’s far more expedient to present strategies as in competition, rather than complementary.”
“It gets to be a very nasty debate,” Stoneburner muses. “The Bush administration and PEPFAR is always beaten up because of the rigidity of funding. And when you talk to the opposition…they say that it’s condoms.”
But, he says, it seems like some people are “finally warming up to the idea” that the answer to South Africa’s HIV epidemic might be a “middle-of-the-road” approach involving many solutions.