AIDS in South Africa: The Invisible Cure

1.

HIV infection rates in South Africa’s townships are among the highest in the world. Hundreds of people contract HIV every day in South Africa, most of them in the poor, often dangerous township communities of crowded tin and concrete shacks. By now, nearly everyone in South Africa knows how HIV is transmitted, and how to avoid it. The enduring mystery is why so many people do not.

Of the roughly half-million South Africans who become newly infected with HIV each year, around half are under age twenty-five. In 1996, anti-retroviral drug cocktails were shown to be effective in treating AIDS symptoms, but these drugs alone cannot resolve the AIDS crisis in South Africa. They are not a cure, they don’t work for everyone, and they are expensive. Few South Africans can afford them, and the South African government, cruelly in the view of many, is only now considering whether or not to offer these drugs to South Africans with AIDS, including the poor. Also, these drugs do not prevent HIV from spreading. Public health campaigns to encourage young people in particular to avoid sex, or at least have fewer sexual partners, or use condoms if all else fails, remain vitally important.

However, to date, many HIV prevention programs in Africa have proven surprisingly unsuccessful. For example, during the 1990s, an ambitious HIV prevention campaign carried out in a South African gold-mining community was held up as a model for the rest of Africa. Health workers raised awareness about HIV using community meetings, drama, and music; condoms were liberally distributed in public places; and treatment services for sexually transmitted diseases such as syphilis, which make it easier for HIV to spread, were greatly improved. But this campaign had no measurable effect on HIV transmission rates. In Uganda, where HIV rates declined in the 1990s, a recent study indicated that this decline was probably not attributable to either the improvement of treatment services for sexually transmitted diseases or a program to encourage safer sexual behavior, including condom use. HIV rates have continued to rise in even those sub-Saharan African countries where the use of condoms has been aggressively promoted in the press and radio and services for treating sexually transmitted diseases have been improved.¹

Why haven’t these programs been more successful?² Many public health experts have tended to regard HIV prevention in Africa as merely a technical problem. But perhaps this view is inadequate. Perhaps in addition to condoms, syphilis treatment kits, sex education modules, and warnings on billboards, something else is required: some shift within the minds of individual people and in the social atmosphere so that AIDS is recognized as the immediate threat that it is.

The one African region that has seen a significant and sustained decline in HIV rates is an arc of territory north and west of Lake Victoria, including most of Uganda and the adjacent Kagera region of Tanzania, where HIV rates fell from around 18 percent in the early 1990s to around 6 percent today. It is becoming increasingly clear that HIV transmission in this region began to decline in the late 1980s, before any of the activities I have mentioned got seriously underway.³ Uganda’s success in combating HIV is generally believed to have been accompanied by powerful social activism, which swept the country in the aftermath of the civil war in the early 1980s. The enlightened policies of Yoweri Museveni’s government, which came to power in 1986, contributed to this movement, including its support for HIV prevention programs in the Ministry of Health, and later in other ministries as well, its supportive attitude toward community-based AIDS organizations, its success in restoring the economy, and its support for greater press freedom, as well as Museveni’s own willingness to openly discuss the epidemic in public.⁴ But also important was an unusually active response to AIDS on the part of ordinary people.

By 1997, more than one thousand Ugandan nongovernmental organizations were caring for people with AIDS and their families and also raising awareness about the risks of HIV infection. Medically, there wasn’t much these organizations could do for people with AIDS, since Uganda’s health care system was destroyed during the war and drugs to effectively treat AIDS were not widely available. However, their activities, mainly feeding and nurs- ing the patients and their families, gave patients some dignity and brought into the open the tragedy of AIDS. Some of these organizations also conducted village meetings, rallies, and drama and musical performances that encouraged people to avoid HIV by remaining faithful to a single sexual partner, or by using condoms. What made many of these events particularly powerful was that the speakers and performers often dealt openly with the effect of AIDS in their own lives. These organizations were established not by the Ugandan government or by foreign agencies, but by individuals who had watched friends and family members die.⁵ Their commitment, and their success, have their roots not only in fear for others and for themselves, but in compassion for the suffering they have witnessed.

Uganda’s success has been hard to repeat in other countries, including South Africa. Part of the problem lies with the South African government’s adversarial relationships with many nongovernmental organizations. In developing the country’s AIDS policies, the Health Ministry has largely ignored the nation’s many AIDS activists and health workers, and has sometimes aggressively disparaged them. A spokesman from the ANC Youth League recently attacked activists who have protested the government’s unwillingness to provide antiretroviral drugs for poor South Africans, calling them “paid marketing agents for toxic AIDS drugs from America.” President Thabo Mbeki has questioned whether HIV really is the cause of AIDS and has entertained theories—dismissed by most scientists—that the disease might also be caused by poor nutrition, unsanitary conditions, and even the very drugs that have been developed to treat the disease. Meanwhile, Mbeki’s minister of health recommended garlic for the treatment of AIDS, and an official in the Department of Housing accused journalists who defended the AIDS activists of fanaticism, and quoted Lenin on how the “press in bourgeois society…deceive[s], corrupt[s] and fool[s] the exploited and oppressed mass of the people, the poor.” The activist groups, meanwhile, have accused the health minister of “murder” for denying millions of South Africans access to medicine for AIDS.⁶

The strained relationship between the South African government and non-governmental organizations has almost certainly undermined efforts to prevent the spread of HIV. In 1998, a group of public health experts from South Africa and the US who were concerned about the worsening crisis decided that South Africa needed a bold new HIV prevention program for young people. They also knew they had to take account of the South African government’s attitudes toward AIDS. Their program, called loveLife, is now South Africa’s largest and most ambitious HIV prevention campaign. It both aims to overcome the limitations of similar campaigns that have failed in the past and, at the same time, it avoids dealing with the issues of treatment and care that have become so controversial in South Africa.

Can this work? Is it possible to prevent the spread of HIV without addressing the needs of HIV-positive people? Epidemiologists will not know for years whether loveLife has any effect on HIV transmission rates. In fact, they may never know, because young South Africans are increasingly exposed to many other HIV prevention programs, and the influences governing sexual behavior are not easy to disentangle in any case. However, loveLife has been endorsed at one time or another by the head of the United Nations AIDS program, the archbishop of Cape Town, Nelson Mandela, Jimmy Carter, Bill Clinton, the king of the Zulu tribe, and even Jacob Zuma, South Africa’s deputy president, and Zanelle Mbeki, the wife of the President. LoveLife’s budget is $20 million a year and it has received large donations from the South African government, UNICEF, the Bill and Melinda Gates Foundation, and the Global Fund to Fight AIDS, Tuberculosis and Malaria, the Swiss-based organization conceived by UN Secretary General Kofi Annan to raise money for health programs in developing countries. For years, these donors, along with the governments of the US, Great Britain, and other developed nations, paid scant attention to the AIDS epidemic in Africa. Now that funding is finally available, it is worth asking how it is being spent.

2.

I met loveLife’s director, David Harrison, an enthusiastic, committed white South African doctor, in Johannesburg in February 2003. “What we want to do is create a substantive, normative shift in the way young people behave,” he explained to me. The average age at which young South Africans lose their virginity—around age seventeen—is not much different from the age at which teenagers in other countries do. What’s different, says Harrison, is that many of the young South Africans who are sexually active are very sexually active. They are more likely to start having sex when they are very young, even below the age of fourteen. They are more likely to have more than one sexual partner and they are less likely to use condoms. South African girls are more likely to face sexual coercion or rape, or to exchange sex for money or gifts, all of which place them at greater risk of HIV infection. For Harrison, the trick is to “get inside the head-space of young people…we have to understand what is driving them into sex—they know what HIV is, but they don’t internalize it,” he said.

In order to do so, he claims, they have to learn to speak openly about sex and about the risk of HIV infection. Behavior change to avoid HIV infection is not a passive process, he explained. Young people must talk to each other and to their parents to really understand and internalize what they know. According to Harrison, traditional HIV prevention campaigns are too depressing, they try to scare people into changing their behavior, and this turns kids off. LoveLife’s media campaign, on the other hand, is positive and cheerful, and resembles the bright, persuasive modern ad campaigns that many South African kids are very much attracted to.

LoveLife’s most immediately recognizable presence is its billboards, of which there are more than a thousand in South Africa. They loom over nearly every major road, and they are striking. For example, on one of them, the hands of four women of different races caress the sculpted back and buttocks of a young black man as though they were appraising an antique newel post. The caption reads, “Everyone he’s slept with, is sleeping with you.” On another, a gorgeous mixed race couple—the boy looks like Brad Pitt, the girl like an Indian film star—lie in bed, under the caption “No Pressure.” Some people told me they found these ads disturbing, but it is hard to see why. On the same roads, there are torsos advertising sexy underwear and half-naked actresses advertising romantic movies; sex is a potent theme in marketing all sorts of products. LoveLife, according to its creators, tries to turn that message around to get young people thinking and talking about sex in ways that will convince them of the virtues of abstinence, fidelity, and the use of condoms.

Harrison calls loveLife “a brand of positive lifestyle.” The sexy billboards and similar ads on TV and radio, as well as newspaper inserts that resemble teen gossip magazines, with articles and advice columns about clothes, relationships, and sexual health, are designed, Harrison says, to persuade young people to avoid sex, in the same way a sneaker ad tries to seduce them into buying new sneakers, because the players in the ads look so cool. The idea is “to create a brand so strong that young people who want to be hip and cool and the rest of it want to associate with it. That is the first step,” Harrison told an interviewer in 2001.⁷ The idea is to convince young people that they can be glamorous and at the same time models of restraint.

The concept of a “lifestyle brand” originated with the rise of brand advertising in the 1960s, when ads for such products as Pepsi-Cola and Harley-Davidson began to promote not only soft drinks and motorcycles, but also a certain style or aesthetic. People were urged to “join the Pepsi generation.” A Harley wasn’t just a bike, it was a way of life, a rebellion, an escape to the open road. Harrison claims that young South Africans readily respond to this approach.

“Kids have changed,” Harrison explained. They aren’t like the young activists who risked their lives in the anti-apartheid demonstrations at Sharpeville and Soweto. “Seventy-five percent of South African teenagers watch TV every day, and their favorite program is The Bold and the Beautiful“—an American TV series in which glamorous characters struggle with personal crises while wearing and driving some very expensive gear. “They are exposed to the global youth culture of music, fashion, pop icons, and commercial brands. They talk about brands among themselves, even if they can’t afford everything they see.”

LoveLife drew much of its inspiration from the marketing campaign for the soft drink Sprite.⁸ In the mid-1990s, sales of Sprite were flagging, until the company began an aggressive campaign to embed Sprite in youth culture, by sponsoring hip-hop concerts, and planting attractive, popular kids in Internet chat rooms or college dormitories and paying them to praise or distribute Sprite in an unobtrusive way. Sprite is now one of the most profitable drinks in the world because it managed to exploit what marketing experts call “the cool effect”—meaning the influence that a small number of “opinion leaders” can have on the norms and behavior of large numbers of their peers. So far, corporate marketers have made the greatest use of this theory, but there is also speculation that small numbers of trend-setters can change more complex behavior than shopping, such as criminality, suicide, and sexuality.⁹

For this reason, loveLife has established a small network of recreation centers for young people, known as Y-Centers, throughout the country. At Y-Centers, young people can learn to play basketball, volleyball, and other sports, as well as break-dancing, radio broadcasting, and word processing. All Y-Center activities are led by “loveLife GroundBreakers”—older youths usually in their early twenties, who, like the kids who made Sprite cool, are stylish and cheerful and enthusiastic about their product, in this case, loveLife and its program of encouraging sexual restraint. If abstinence, monogamy, and condoms all happen to fail, each Y-Center is affiliated with a family planning clinic that offers contraceptive pills and condoms, and treatment for sexually transmitted diseases such as syphilis and gonorrhea. The centers offer no treatment for AIDS symptoms, however, and only some of them offer HIV testing.¹⁰

Any young person can become a Y-Center member, but in order to fully participate in its activities, he or she must complete a program of seminars about HIV, family planning, and other subjects related to sexuality and growing up. The seminars emphasize the biological aspects of HIV and its prevention but not the experience of the disease and its effects on people’s lives. According to loveLife, these seminars provide information that young people may not receive from their parents and peers, but that helps them make informed decisions about their own sexual behavior. Members also receive training to raise their self-esteem, because, as Harrison told an interviewer in 2001,

There is a direct correlation between young people’s sexual behavior and their sense of confidence in the future. Those young people who feel motivated, who feel that they have something to look forward to—they are the ones who protect themselves, who ensure that they do not get HIV/AIDS…. It’s all about the social discount rates that young people apply to future benefits.¹¹

In February 2003, I visited a loveLife Y-Center in the archipelago of townships in the windswept plain south of Johannesburg known as the Vaal Triangle. Millions of people live in these townships, many of them recent migrants from rural South Africa or from neighboring countries. The Vaal, once a patchwork of white-owned farms, is now a residential area for poor blacks. At first only a few families moved here, because the apartheid government used the notorious pass laws to restrict the tide of impoverished blacks seeking a better life in Johannesburg. But when the apartheid laws were scrapped, people poured in, many of them unable to afford the more upscale suburbs of Alexandra and Soweto closer to the city. Today, the roads and other services in the area are insufficient for its huge and growing population, and many people have no electricity and lack easy access to clean water and sanitation. Unemployment exceeds 70 percent and the crime rate is one of the highest in South Africa.

The loveLife Y-Center is a compound of two small lavender buildings surrounded by an iron fence and curling barbed wire. Inside the compound, a group of young men in shorts and T-shirts were doing warm-up exercises on the outdoor basketball court, while girls and barefoot children looked on. Inside the main building, another group of boys in fashionably droopy jeans and dreadlocks practiced a hip-hop routine, and two girls in the computer room experimented with Microsoft Word.

Valentine’s Day was coming up, and the Y-Center had organized a group discussion for some of its members. About thirty teenagers, most of them in school uniforms, sat around on the floor of a large seminar room and argued about who should pay for what on a Valentine’s Day date. A GroundBreaker in a loveLife T-shirt and a loveLife kerchief tied pirate-style on her head presided. “I go with my chick and I spend money on her and always we have sex,” said one boy. “And I want to know, what’s the difference between my chick and a prostitute?” Transactional sex—sex in exchange for money or gifts, which may not be explicit prostitution—puts many township girls at risk of HIV.¹² The need, or desire, for money, a cell phone, a new outfit, or some other present draws girls and young women into sexual relationships with older men who might be infected with HIV. In these relationships, girls often cannot, or do not, ask men to use condoms, or even discuss them.

“Boys, they are expecting too much from us. They say we are parasites if we don’t sleep with them,” said a plump girl in the uniform of a local Catholic school. “The girls they ask for a lot of things,” a boy chimed in. “Me, I think it is wrong. If most of the boys think Valentine’s Day is about buying sex, the boys must stop.” A girl said, “We girls must hold our ground.”

These young people were certainly talking openly about sex, according to Harrison’s prescription. Nevertheless, I felt something was missing. “Do you ever talk about AIDS in those discussion groups?” I asked the GroundBreaker afterward. “We do it indirectly,” she replied. “We know that if we just came out and started lecturing them about AIDS they wouldn’t listen. They would just turn off. So we talk about positive things, like making informed choices, sharing responsibility, and positive sexuality….”

Was this true? Do young people in South Africa, like their politicians, really want to avoid the subject of AIDS? I wanted to meet young people outside the Y-Center and ask them what they thought about that. A few hundred yards away from the Y-Center I visited is the headquarters of St. Charles Lwanga, a Catholic organization that carries out a number of activities in the township. Their AIDS program, called Inkanyezi, meaning “star” in Zulu, provides counseling to young people about AIDS and also brings food and other necessities to some four hundred orphans and people living with AIDS in the Vaal.

St. Charles Lwanga is independent of loveLife, and its budget is modest, less than a tenth of what loveLife spends on its billboards alone. The Inkanyezi program is staffed almost entirely by volunteers, whose only compensation is that they are allowed to eat some of the food—usually rice and vegetables—that they prepare for the patients. Lack of funding greatly limits the help that Inkanyezi is able to provide. Although Inkanyezi nurses dispense tuberculosis medicine, antiretroviral drugs are currently much too expensive. Indeed, the patients they visit often lack some of the most basic necessities for life and human dignity. Sometimes destitute patients have their water and electricity cut off, and this makes it harder to wash and care for them. But the worst thing is that many of the patients are socially isolated and live alone in flimsy shacks. The doors are easily broken down and at night neighborhood thugs come in and steal everything, and even rape the patients.¹³

Justice Showalala, who runs Inkanyezi, organized a meeting for me with a group of young people from Orange Farm, a township in the Vaal Triangle. About twenty-five people showed up, and we divided them into three smaller groups. HIV rates in Orange Farm are not known, but several of the young people in the group explained to me how their lives had been changed by the virus. They said they had witnessed extreme prejudice and discrimination against people with AIDS, and they did not know where to turn when they learned that a relative or friend was HIV-positive. “People say you shouldn’t touch someone with HIV,” said one girl. “I have a friend at school who disclosed she has HIV, and the others won’t even walk with her.” Justice explained how he had offered to introduce some teachers from a local school to some of his HIV-positive clients. “They said, ‘If you want me to meet people with AIDS you better give me a rubber suit.'”

The loveLife Y-Center does little to help young people deal with such confusion, stigma, and shame. It does offer individual counseling for a small number of young people with HIV, but those who are hungry, homeless, or destitute, or who are suffering from the symptoms of AIDS, are told to consult other NGOs, including Inkanyezi. In general, although sex is openly discussed at the Y-Center, the experience of AIDS is not. One girl told me, “I learned basketball at the Y-Center, and at meetings we talked about resisting peer pressure, [like when] your friends advise you to break your virginity, to prove you are girl enough. But I was afraid the people there would find out my sister had HIV. We talked about it as though it was someone else’s problem.”

Far more difficult than the embarrassment of talking about sex is dealing with the pain, both physical and emotional, that the virus creates. “I had heard about HIV before,” said another girl, wearing a bright blue T-shirt and matching headband. “But then I found out my mother was HIV-positive. I was so shocked, so shocked. I even talked to my teacher about it. She said it can happen to anyone, it must have been from mistakes my mother made, and that I shouldn’t make those mistakes in my own life.”

The older woman sitting next to the girl in blue gently corrected her daughter. “Sometimes, women have no choice,” she said. She was thin, with intense dark eyes and a deep wry smile. She was dressed entirely in black, except for a baseball cap with a red ribbon on it—the universal symbol of solidarity with HIV-positive people. “They get infected because of their husbands, and there’s nothing they can do.

“It happened like this,” the older woman went on. “It was back when we were living in Soweto, before we moved here. One day we were washing clothes together. My daughter said she’d had a dream that I was so sick, that I had cancer and I was going to die. I waited until we were done with the washing, and then I told her that I was HIV-positive. She said, ‘I knew it, you were always sick and always going to support groups.’ She was so down, she just cried all day and all night after that. I told her, ‘Only God knows why people have this disease. Don’t worry, I won’t die right away.’

“Once I visited the loveLife Y-Center,” the woman continued, “but I just saw children playing. I sat and talked with them, and they were shocked when I said I was HIV-positive. I told them about what it was like, and one of them said she would ask the managers whether I could come and talk to a bigger group. But that was about six months ago and they haven’t called me. I haven’t moved and my number hasn’t changed. I don’t know why they haven’t called.”

“I think there should be more counseling and support groups for people who find out their parents are HIV-positive,” the girl in blue said. It puts you down, it really gets to you, it haunts you. When you are standing in class and you have to recite a poem or something, I find I can’t get anything out of my mouth. I can’t concentrate. [The problem] here is ignorance. I didn’t care about HIV until I found out about my mother. Then I started to care about these people. I wish many people in our country would also think like that.”

3.

Some of the most perceptive research about the decline of HIV rates in Uganda has been carried out by Rand Stoneburner and Daniel Low-Beer of Cambridge University, who have long experience with the AIDS epidemic in the US and in Africa. They believe that what contributed most to the decline in HIV infection rates in Uganda was the ordinary, but frank, conversations people had with family, friends, and neighbors—not about sex—but about the frightening, calamitous effects of AIDS itself.¹⁴ Stoneburner and Low-Beer believe these conversations did more than anything else to persuade Ugandans to avoid risky sexual behavior, which in turn led to declines in HIV transmission. The researchers found that people in other countries were far less likely to have such conversations.

Both in Zimbabwe and South Africa people told Stoneburner and Low-Beer that they had heard about the epidemic from posters, radio, newspapers, and clinics, as well as occasional mass rallies and village meetings; but they seldom spoke about it with the people they knew. They were also far less likely to admit knowing someone with AIDS, or to be willing to care for an AIDS patient. It may be no coincidence that HIV rates in these countries are now higher than they ever were in Uganda, and they are falling far more slowly, if at all.

In Uganda, where I spent much time during the early 1990s, when HIV rates were already falling, the reality of AIDS was alive in people’s minds. Kampala taxi drivers talked as passionately about AIDS as taxi drivers elsewhere discuss politics or football. And they talked about it in a way that would seem foreign to many in South Africa because it was so personal: “my sister,” “my father,” “my neighbor,” “my friend.”¹⁵

Ugandans are not unusually compassionate people, and discrimination against people with AIDS persists, especially in institutions like banks and the army; but Ugandans do seem more willing to openly address painful issues in their lives. This courage owes much to the AIDS information campaign launched by the government of Uganda as early as 1986, but it may have other sources as well. Maybe the difference between the ways South Af- rica and Uganda have dealt with AIDS has historical roots. Both South Africa and Uganda have bitter histories of conflict. But while Uganda was terrorized for decades by a series of brutal leaders, they could not destroy the traditional rhythms of rural family life. Uganda is also one of the most fertile countries in Africa; there is enough land for everyone, and most people live as their ancestors always have, as peasant farmers and herders. No large settler population ever came and displaced huge numbers of people, or set up a system to exploit and humiliate them, as happened in South Africa and in many other African countries. This means Ugandans are more likely to know their neighbors, and to live near members of their extended families. This may have contributed to what sociologists call “social cohesion”—the tendency of people to talk openly with one another and form trusted relationships. This in turn may have facilitated a more realistic and open discussion of the AIDS epidemic, which in turn encouraged people to take steps to protect themselves.¹⁶

Perhaps many attempts to prevent the spread of HIV fail because those in charge of them don’t recognize that the decisions people make about sex are usually a matter of feeling, not calculation. In other words, sexual behavior is determined less by what Dr. Harrison calls “social discount rates” than by genuine emotions. I thought of the South African girls who said they had lost a sister or a friend to AIDS. If one of them was faced with a persistent, wealthy seducer, what would be more likely to persuade her to decline? The memory of a loveLife seminar, or the memory of a person she had known who had died?

4.

On the morning before I left South Africa, I attended a loveLife motivational seminar at a school not far from Orange Farm. “These seminars help young people see the future, identify choices, and identify the values that underpin those choices,” Harrison had told me. “We help them ask themselves, ‘What can you do to chart life’s journey, and control it as much as possible?'” The seminars are based on Success by Choice, a series devised by Marlon Smith, a California-based African-American motivational speaker. How was Mr. Smith’s message of personal empowerment translated to South Africa, I wondered, where children have to contend with poverty, the risk of being a victim of robbery or rape, and a grim future of likely unemployment?

About twenty-five children aged ten to fourteen were in the class, and the GroundBreaker asked them to hold their hands out in front of them and pretend they were looking in a mirror, and repeat the following words:

“You are intelligent!”

“You are gifted!”

“There is no one in the world like you!”

“I love you!”

The children spoke quietly at first, then louder, as though they were being hypnotized. The GroundBreaker urged them to talk more openly with their parents, to keep clean, and to make positive choices in their lives, especially when it came to sexuality. There was little mention of helping other people, nor was there much advice about how to avoid being raped or harassed by other students as well as teachers, relatives, or strangers, or how to plan a future in a country where unemployment for township blacks is so high.

Then something really odd occurred. One of the GroundBreakers asked the children to stand up because it was time for an “Icebreaker.” “This is a little song and dance thing we do, to give the children a chance to stretch. It improves their concentration,” I was told. The words of the song were as follows:

Pizza Hut
Pizza Hut
Kentucky Fried Chicken and a Pizza Hut
McDonalds
McDonalds
Kentucky Fried Chicken and a Pizza Hut.

In the dance, the children spread their arms out as though they were rolling out a pizza, or flapped their elbows like chickens.

What kind of choices was Dr. Harrison really referring to? I wondered. The techniques of marketing attempt to impose scientific principles on human choices. But it seems a mad experiment to see whether teenagers living through very difficult times can be persuaded to choose a new sexual lifestyle as they might choose a new brand of shampoo, or that children can be trained to associate safe sex with pizza and self-esteem.

Afterward, I spoke to some of the children who had participated in the seminar. They all knew how to protect themselves from HIV, and they were eager to show off their knowledge about condoms, abstinence, and fidelity within relationships. But they all said they didn’t personally know anyone with AIDS; nor did they know of any children who had lost parents to AIDS. They did mention Nkosi Johnson, the brave HIV-positive twelve-year-old boy who became world-famous in 2000 when he stood up at an International Conference on AIDS and challenged South African president Thabo Mbeki to do more for people living with the virus.

In fact, their principal would tell me later, more than twenty children at the school were AIDS orphans, and many more had been forced to drop out because there was no one to pay their expenses after their parents died. The children seemed not to know why some of their classmates wore ragged uniforms or had no shoes or stopped showing up at all.

The week before, I had met some teenage girls in Soweto and I had asked them the same question. They answered in the same way: the only person they knew with AIDS was Nkosi Johnson, the famous boy at the AIDS conference. They were bored of hearing about AIDS, they said. The girls were orphans, although they said their parents had not died of AIDS. I later discovered that in another part of that same orphanage, there was a nursery where thirty babies and small children, all of them HIV-positive, all abandoned by their parents, lay on cots or sat quietly on the floor, struggling for life. No wonder those girls were tired of hearing about HIV. It was right in their midst, within earshot, but the world around them was telling them to look the other way.

The persistent denial of AIDS in South Africa is striking and deeply mysterious. It has to be confronted. Overcoming such denial is what seems to have made the greatest difference in Uganda, and may well be the factor that will have the greatest impact on the epidemic elsewhere in Africa. People like the colorful, frank advertising and the basketball games sponsored by loveLife. But its programs may well be reinforcing the denial that poses so many obstacles to preventing HIV in the first place. A more realistic program to prevent AIDS should pay greater attention to the real circumstances in people’s lives that make it hard for them to avoid infection. It should also be more frank about the real human consequences of the disease. But this means dealing with some very painful matters that South Africa’s policymakers seem determined to evade.

Traveling around Africa in the past year, I came across many small AIDS projects that have recently lost their financial support or were struggling to continue their activities. Some, like St. Charles Lwanga and Huyawa in northern Tanzania, were providing care to AIDS patients and orphans; others, such as WAMATA in Tanzania, were organizing counseling groups for people with HIV; others, like TAWOBEL, also in Tanzania, were helping impoverished prostitutes find new ways to earn a living.

It is heartening that Western nations are now planning to spend several billion dollars on AIDS in Africa in the coming years. But how will this money be spent? Much of it will be administered by the Global Fund, by the World Bank’s Multi-Country HIV/AIDS Program, and by President George Bush’s multibillion-dollar AIDS plan. The problem with these programs and other huge initiatives to do something about the AIDS crisis in Africa is that the mechanisms to distribute the funds often involve governments with a poor record of dealing with AIDS. In addition, the huge sums of money involved are very difficult to manage, so that small community-based groups that need thousands of dollars, rather than millions—like the NGOs that made such a difference in Uganda, and like Inkanyezi in Orange Farm—are often overlooked in favor of overly ambitious megaprojects, whose effectiveness has not been demonstrated and whose premises are open to question. It seems clear that there is more to be learned from Inkanyezi’s attempt to help people deal with the reality of AIDS than from loveLife’s attempts to create a new consumerist man and woman for South Africa.