March
2000
At
The Center Of An Epidemic: South Africa In The Grip Of AIDS
The Satya Interview with Nicola
Christofides
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Nicola Christofides is a researcher
at the Women’s Health Project (WHP), a non-governmental organization
based in Johannesburg, South Africa. WHP works to ensure gender equality
and provision of high quality health services through research, advocacy,
training and information dissemination. Christofides recently undertook
a qualitative evaluation of South Africa’s government-initiated
communication campaigns on HIV/AIDS. Mia MacDonald asked her
about the factors fueling the spread of HIV/AIDS in South Africa, the
high infection rates among women and what the responses of communities
and governments have been.
What is the scope of HIV/AIDS in
South Africa?
For a start, rates vary widely between areas, with rural areas having
higher rates of infection than urban areas. In some rural areas, infection
rates are reported to be as high as 60 percent, with the national average
between 10 and 20 percent of the sexually active population. In 1999,
nearly five million people in South Africa had HIV. In 2000, the number
is expected to rise to 5.6 million. Heterosexual transmission rates
are the highest, and women are particularly vulnerable. Indeed, more
women in South Africa have HIV than men—2.7 million women were
living with HIV in 1999, and 3.15 million are expected to be living
with it in 2000. That means that about 57 percent of HIV infections
in South Africa are among women. Throughout Africa, between 12 and 13
African women are infected with HIV for every 10 African men. HIV/AIDS
in South Africa is also affecting racial groups differently, with the
black population disproportionately affected. Infection rates for whites
and Asians remain very low, while infection rates for the colored population
[people of mixed race] are five years’ behind that of blacks.
What are the projections of how far
and fast HIV/AIDS will spread in the future?
South African infection rates are still below those of the rest
of Southern Africa, but that is expected to change, and quickly. Between
1996 and 1997, infection rates among women under 20 increased by 65
percent. A recent study suggests that HIV infections will peak in 2006,
with 16 percent of people in South Africa having HIV. Among what’s
defined as the economically active population, infections will peak
at 22 percent. Semi-skilled or unskilled workers will be the hardest
hit, with nearly one-third having HIV within six years—those employed
in mining, government, transportation, construction and consumer manufacturing
are expected to have the highest infection rates. But highly skilled
workers will also face a 12 percent infection rate, not insignificant.
It is also thought that the growing number of HIV/AIDS cases will have
a negative impact on the economy: after 2005, South Africa’s gross
domestic product (GDP) is projected to grow more slowly as funds are
diverted from savings to paying for the costs of care for those with
HIV/AIDS. Also, because of the impact of AIDS, life expectancy throughout
Southern Africa is dropping, from 59 in the early 1990s to just 45 between
2005 and 2010.
What are the major factors fueling
the spread of HIV/AIDS in South Africa?
There are a number of factors, but a major one is economic. In many
Southern African countries, men have jobs away from their families and
may engage in sexual relations in the cities or towns where they work.
This increases their risk of getting HIV. Then, when they return home,
they can transmit it to their wives. Husbands may be reluctant to use
condoms with their wives because they do not want to appear unfaithful
or because they want to have children. "[Condoms] might send wrong
messages to our wives because it may look like we are sleeping around
with other women," said one man in a focus group discussion. In
most relationships, women do not have the power to insist on the use
of condoms.
Gender relations and power differences
between women and men seem to be central to the spread of HIV/AIDS in
many countries. Can you comment on this in the South African context?
Persistent inequalities between women and men make women vulnerable
to HIV: the low social status of women makes it difficult for them to
control where, when and with whom they have sex. Decisions about sex
are considered "men’s business" and women and men rarely
discuss sex. In addition, women’s powerlessness in their relationships
increases their risk. Women often cannot confront men about their sexual
activities or demand faithfulness, and double standards about sex exist
throughout the society. These make it acceptable for men to have more
than one sexual partner but not for women. So, as one of the people
I interviewed for a study asked, "How does [condom awareness] relate
to the everyday lives and status of women? [The] safety of women? The
right of women to negotiate sexual activity?"
Poverty can also make women vulnerable to exploitation. Women in South
Africa earn less than men and more women are unemployed. Yet, women
are often fully responsible for supporting their families. The pressure
of this can lead to women engaging in transactional sex—where sex
is exchanged for food or clothing. Again, in these situations, women
may find it difficult to insist on the use of condoms and therefore
increase their vulnerability to HIV. Another result of the unequal power
relations between men and women is that young women are vulnerable to
unwanted, coerced or unprotected sex and its consequences—among
them the risk of sexually transmitted diseases (STDs), including HIV.
Also, access to health services is often a problem for young people
in South Africa.
Are there also biological factors that increase women’s risk
of contracting HIV?
Yes, HIV is transmitted more easily from men to women than from
women to men. This is because women’s sex organs are internal.
Semen is held in the vagina, which means that the exposure is greater
and therefore the risk of infection is increased. Cultural practices
such as "dry sex" can also increase women’s risk of getting
HIV. Dry sex stems from beliefs that a dry vagina means better sex.
Women make their vaginas drier with all sorts of dangerous substances
[sometimes chemicals and sometimes herbs], which increases the likelihood
of scratches or tears in the vagina during intercourse—increasing
the risk of transmission of STDs, including HIV.
What are the biggest obstacles to confronting and ending the HIV/AIDS
epidemic in South Africa?
Denial is still prevalent, and was viewed by many of the people
I interviewed as the biggest barrier to the impact of the government’s
communication campaigns on individuals, organizations and institutions.
Denial manifests itself on both individual and institutional levels.
As someone said during my evaluation: "It’s like smoking cigarettes.
We have warning labels: people know the dangers but still smoke."
There are still many myths and misconceptions about HIV that reinforce
ideas of invulnerability; one that I was told about is that if a woman
is light-skinned, she is less likely to be HIV positive. Although more
and more people are aware of the risk of HIV and understand how to protect
themselves, they are still inclined to believe that "it won’t
happen to them." HIV is also related to sex, and for many people,
sex is a taboo subject. But as one of the people I interviewed said,
"HIV/AIDS has ignored the taboos, so we should too."
Health service delivery is often inadequate, from dissemination of information
on HIV/AIDS prevention and condoms, to provision of counseling before
and after HIV testing, to care for people living with AIDS. There is
also a lack of resources in many parts of the country to carry out communication
campaigns on HIV/AIDS, including funding, technical skills and time.
What has been the general response of the government to the spread
of HIV/AIDS?
There are many communication campaigns that have received support
from the government. The two largest are the Partnership Against AIDS,
originating in the President’s office, and Beyond Awareness, a
Department of Health initiative. There are also many other forums and
committees that link government departments on the national and provincial
level. Most sectors [e.g., education, employment] have policies on HIV/AIDS
that are at various stages of implementation. The Partnership Against
AIDS was launched by then Deputy President [now President] Thabo Mbeki
in October 1998, and uses a multi-sectoral approach, with many different
parts of society participating. The aim of Beyond Awareness is empowerment
through the provision of resources. It focuses on HIV prevention as
well as care and support for those with HIV/AIDS. It targets young people
aged 15 to 25 by promoting condom use; and explores issues of gender,
rights and social action through the media, training, and outreach/action
initiatives. Beyond Awareness also promotes the wearing of a red ribbon
[the international symbol for HIV/AIDS] to ensure visibility of the
epidemic.
Most people I spoke with said that the government has improved its efforts
to raise awareness of HIV/AIDS over the past several years, and that
for many individuals, awareness of the reality of HIV/AIDS is high;
however, levels of understanding of how HIV is transmitted are variable.
Also, the campaigns appear to be having less of an impact in rural areas
than in urban ones. People in rural areas have less access to the media,
lower literacy levels and some of the underlying factors contributing
to the spread of HIV, like migrant labor and poverty, have the greatest
impact. Also, communication campaigns alone can’t be expected to
result in behavior changes like increased condom use, abstinence from
sexual activity, or having only one sexual partner. "It is a different
ball game with HIV/AIDS compared to, say, breast cancer which involves
just me and my breasts," noted one of the people I interviewed.
"HIV/AIDS is so different: using a condom needs behavior change
to be initiated and sustained, and the issue is so personal – both
people must agree to use condoms." Or, as another person said,
behavior will change only when HIV/AIDS affects people directly: "When
people start dying all around, behavior will change." Commitment
by all sectors, government and all those in society at large, is seen
as key to the success of government-sponsored communication campaigns.
How have the gender realities been confronted by any of the ongoing
campaigns?
One effort in this direction is the Sexual Rights Campaign, launched
by the Women’s Health Project in alliance with a number of partners,
including the National AIDS Convention of South Africa, the National
Association of People Living with AIDS, and the National Network on
Violence Against Women. Its goal is to work through broad segments of
society—such as youth, health workers and religious leaders—to
promote the idea, and reality, of equality and mutual respect in sexual
decision-making between women and men. The Campaign is in the process
of developing a Sexual Rights Charter, as well as training educators,
running workshops, and developing an action agenda on adolescent sexual
health, AIDS and violence against women. Among the central tenets of
the Charter will be that all people should have: the right to choose
when, with whom and how to have sex; the right to a respectful sexual
relationship; and the right to enjoy pleasurable and safer sex. Of course,
millions of women in South Africa, and many men, don’t enjoy these
rights at all. The campaign is seeking to let women know that they have
these rights, and to help them exercise them. Training and outreach
are being undertaken with both men and women and adolescent boys and
girls.
From your recent evaluation, what are the priority actions South
Africa needs to take to stem the HIV/AIDS epidemic?
For communication campaigns, the general consensus is that they
need to combine elements of raising awareness, addressing the underlying
factors contributing to the spread of HIV, and informing people about
what they can do. It was agreed that not focusing on underlying issues,
particularly women’s status and rights, and poverty, is just putting
on a "band aid." Campaigns also need to be segmented, with
messages and outreach strategies developed for particular groups in
society, for example young people, rural women or migrant laborers.
Of course an essential element, beyond the communication efforts, is
providing adequate health services: people need to know where they can
get information on HIV/AIDS and condoms. If people choose testing, there
needs to be adequate facilities for pre- and post-test counseling on
what they can do. People living with AIDS should have options for care
both within the health system and home-based care. It was agreed that
community-based organizations and NGOs can play an important role in
service provision, more than they do now, particularly in providing
care and support for people living with AIDS and children orphaned by
AIDS. Communities need to be mobilized and provided with resources—both
technical and financial—through community-based organizations.
Political leadership is also critical. It was agreed that politicians
and ministers should view every platform they have as an opportunity
to speak out about HIV/AIDS. "Ministers must walk the walk and
talk the talk," one of the interviewees said. "They must not
remove themselves from the community when it comes to fighting AIDS.
The approach should be ‘we’ are striving, rather than ‘you.’"
Some U.S. and European drug companies claim that they are making new
drugs that can slow the progression of HIV (now available in the "First
World") accessible to people in low-income ("Third World")
countries. What is your assessment/experience of these claims?
In the South African context, AZT is only being discussed with regard
to using it to reduce the likelihood of pregnant women transmitting
HIV to their child. Its projected use is only for prevention—not
treatment. Equity remains the biggest issue: the contrasts between First
World and Third World health services mean that it is unlikely that
people here and in most other developing countries will have equal access
to the drugs being developed in Europe and the U.S. Currently, rural
primary health services in South Africa do not have the facilities or
trained staff to carry out HIV testing, and health service providers
do not have counseling skills. This speaks to the issue of the urgent
need for improved health services. As one of the people I interviewed
for my evaluation said, "[AIDS] highlights all that is wrong in
society: the gap between the rich and poor, the problems with the health
system [and] the power that men have over women."
For more information on HIV/AIDS in South Africa, visit the Website
of the Joint United Nations Programme on HIV/AIDS (UNAIDS): www.unaids.org.
Trading in Priorities: A South African Talking
Head
Dr. Ian Roberts—in his fourth year as special
advisor to South Africa’s health minister—made his first trip
to an important AIDS conference held recently in San Francisco (January
30 to February 2). Although his country is in the grip of an AIDS epidemic,
his attendance at the Conference on Retroviruses and Opportunistic Infections
was accompanied by little fanfare, and he never officially registered
for it. This annual conference is considered a can’t-miss event
among researchers and officials from around the world.
Roberts is not directly responsible for policy changes, but he has been
criticized by activists and industry alike for his apparent lack of
urgency and what they see as flippant responses to questions about specific
treatment plans. Perhaps what illustrates this most is that, when reminded
in an interview of a drug regime that had some proven benefits, he replied
"They’re entitled to their opinion." Below are a choice
selection of comments that he made in an interview for Salon.com.
It’s not a question of do we have the budget. It’s that if
we don’t solve it, the ramifications are going to be enormous.
We’re looking at the total picture—trying to understand reducing
transmission. I don’t dispute that nevirapine lowers transmission,
but we have to deal with the problem from a holistic perspective. Treatment
might be important, it might not be.
Often, the easiest answer is for policy makers to roll out a [new policy].
Government can stand up and say ‘We’re really doing something
in AIDS now’—and at 2 years old the kiddies are still dying,
and everyone’s lost hope. Once we know the results [of drug trials]
we’ll go back to the minister for her policy decision.
What I want to avoid is self-perpetuating publication of papers. Science
can either produce more publications or it can impact on the social
reality of people infected. You have to have some solid evidence about
what you’re doing. The danger of rolling out public health policies
based on anecdotal evidence is that they’re very difficult to reverse.
AIDS is not only a South African problem. Everyone should be working
on it. It’s not just what am I going to do when I get back—it’s
what everybody who I talked to [at the conference] is going to do.
The problem with transformation is that there are many, many, many things
that are compelling. Priorities have to be traded all the time. It’s
almost like managing chaos theory. AIDS is one of our problems. I think
it’s a very big problem. But in fact the evidence that’s coming
out of Africa at the moment is that many, many women are concerned about
getting access to clean water, medical care for their kiddies. I don’t
know how to prioritize.
I think we must do something and do something quite quickly. Whether
this is the right strategy—setting up trials and setting up networks—I
don’t know.
The danger is that I go back home, send in another report, another crisis
pops up somewhere else, I focus on that, and then suddenly wake up an
find out I’m not registered in Durban either [at the World AIDS
Conference, July 2000]. In South Africa we’re passing 120 pieces
of legislation a year to turn ourselves from an apartheid-based system
into a democracy…you can’t focus that easily on everything
else. It’s our reality. We can’t shift it.
For more information and to read the full interview, visit www.salon.com
