Mail and Guardian, 4 October 2002, Prevention Means More Than Condoms, Suzanne Leclerc-Madlala
The irony of our failure to halt the rapid spread of HIV, is that this very failure will halt the rapid spread of HIV.
With more than half of all deaths now attributed to Aids-related illnesses, those returning from funerals are now acknowledging a "new disease" is the cause of death.
Some people have now come to see the wisdom of sexual behaviour change. Perhaps it is better late than never, but it is a sad indictment of more than a decade of work on Aids that was mostly prevention focused. With the epidemic's maturation causing issues of treatment and care to come to the fore terms like "risk profile", "awareness" and "sexual negotiations" seem to be from an age of innocence. Having HIV/Aids in our homes, killing our loved ones, the sensitive language of prevention has given way to the more direct language of treatment. People demand treatment. People demand government action. That demand verb was never part of our prevention vocabulary. We were never motivated enough to organise marches demanding prevention.
HIV prevention is poised to take its place as a component of a broader continuum of activities to address Aids. Perhaps now is a good time to reflect on our prevention efforts that have done little to reverse our trend of ever-rising HIV infections.
More so than any other African country, we have had the benefit of resources to put together a sophisticated media blitz against Aids.
We have been able to develop an exemplary national campaign aimed at youth encouraging them to take control of their lives and their developing sexualities. This slick, multi- media campaign has found its way into nearly every South African home.
Yet one wonders whether the promotion of this youth culture actually helps to better the life chances of the majority of our youth who are at the frontline of the Aids tsunami.
Spiked of hair and pierced of navel, these beautiful, hip, straight-talking teens could just as soon be kids from Los Angeles or Glasgow as from Alexandra or Tugela Ferry. Perhaps this is the point; youth everywhere face similar challenges when it comes to looks, love and life in the era of Aids.
Indeed, the concerns of young people the world over may be similar, but a case needs to be made for engaging more directly with the local context. The youth are portrayed as middle class, sophisticated and seem likely to spend their weekends enjoying multi-racial camaraderie in suburban rave clubs. Wittingly or unwittingly, the thrust of our national HIV/Aids prevention effort speaks primarily to a narrow band of privileged youth. We can only assume that this social prejudice has not been intentional.
When it comes to reducing HIV infection rates, we have nothing at all to teach the rest of Africa. Rather, some much poorer countries have much to teach us. Uganda's success in lowering HIV prevalence from a high of 21% in 1991 to a mere 6% in 2001 is largely unique for sub-Saharan Africa.
As researchers start to pick through the reasons for this success, one troublesome fact emerges: condoms had little to do with it. Ugandan men never really took to condoms. Rather, the biggest reported differences in behaviour had to do with real behaviour change and the development of social support for abstinence and faithfulness. A recent Harvard study revealed a drastic reduction in multiple sexual partnering, from a reported rate of 18% in 1989, down to 8% in 1995, descending to around 2% this year.
As unlikely as it may sound, Uganda's experiences suggest that the promotion of abstinence before marriage and mutual faithfulness in relationships may be the keys to halting the spread of Aids in Africa.
According to a World Health Organisation official, Uganda's model for Aids prevention has the potential to reduce Aids rates in hard-hit countries by 80%.
But promoting abstinence and mutual faithfulness in South Africa would not be easy. For a start we are dogged by a serious reluctance to come to terms with the basic facts of the epidemic. There is even reluctance to accept the idea that it has much to do with sexual responsibility. Beyond that, abstinence and faithfulness are unpopular notions. Who would be willing to produce glossy media materials to convey such killjoy messages?
Local responses to spiraling HIV infection rates should enlighten us about approaches that might prove effective. For example, the growth in the popularity of virginity testing.
It would be nice to think that those women who advocate genital inspection are deranged aunties out to psychologically destroy our girl children. But the truth is that 99,9% of those promoting testing really want to encourage abstinence before marriage.
This may be a peculiar way of doing it, perhaps, but we need to ask where are the programmes to assist mothers in imparting values to their children? It is time to take a look at our assumptions about youth and how we conceptualise HIV prevention. Our preoccupation with condoms has left little room for the development of a holistic approach to HIV prevention.
Talking abstinence and faithfulness may conjure up fears of preaching morality and identifying with the faith-based sector, but it is worthwhile common ground to exploit. It offers us an opportunity to enact the principle of partnership and to act comprehensively in our response to HIV/Aids.
In a raging epidemic such as we have here, messages that promote real sexual behaviour change are about far more than moral choices. They are about sensible health choices and basic survival tactics.
Now that epidemiological events are overtaking us, perhaps forces are converging that will prompt us into more balanced and comprehensive approaches to this epidemic.
As things are, there is very little to lose by trying.
Suzanne Leclerc-Madlala is a medical anthropologist and head of the anthropology programme at the University of Natal.