A new book on SA’s HIV/AIDS epidemic contains contributions from scientific experts such as Olive Shisana alongside politicians such as Barack Obama and celebrities such as Elton John. In this edited extract of the introduction, reflects on the progress m
Sizonqoba! Outliving AIDS in Southern Africa, edited by Busani Ngcaweni
The narrative of the AIDS epidemic shifted over the past decade to become the story of how a nation clawed its way out from under the unbearable weight of death from the disease. What is the real story of this monumental transition? Was it due to political change, phenomenal advancements in science, or the development of drugs and diagnostics? Or did the ground-level pressure of the activists, clinicians and the nongovernmental organisations – those that battled daily with the virus – eventually break through? Can we claim to be winning the war against AIDS with almost 400 000 new HIV infections in the past year alone, and without any decline in the absolute number of new infections between 2010 and 2015?
The 1994 democratic breakthrough marked a significant turn for those who had suffered for centuries under racial segregation in all facets of social, political and economic life. For its part, the liberation movement presented a humanist and inclusive vision of a new society characterised as democratic, nonracial, nonsexist, united and prosperous. By building the biggest international solidarity movement in modern history, the liberation movement successfully mobilised the international community to take a moral stand by isolating the apartheid regime.
In the following years, this triumph of the human spirit and international solidary would return to save South Africa from yet another existential threat: the AIDS epidemic. By and large, this epidemic was present but not making headlines until after the 1994 democratic order.
Soon thereafter, historical images of apartheid massacres, the iconography of township life and rural poverty were replaced by images of suffering orphans and funerals. This would proceed to change the tone for a new government engaged in transformative midwifery, giving the country the odious crown of capital of the world, alongside its emergence as the world’s newest and most miraculous democracy.
Had HIV been purely a biomedical issue, it may have been a different challenge to confront as the solution would have been largely scientific – engineered in a laboratory. It became apparent that it is as much a social and economic issue, the management of which depends on political will and bold leadership. The virus had “contaminated” our social fabric too, thriving in the threads and weaves of moral judgment, religious and cultural prejudice and the broad fabric of stigma arising from fear, ignorance and the narrow focus on heterosexual transmission.
The national turnaround – in terms of public policy, partnerships and resource mobilisation – has, in the past decade or so, shifted the country’s focus from those early days of crowded cemetery processions to the hope, relief and dignity secured for millions of South Africans by the biggest response programme in the world. Many mortuaries have since closed shop as fewer people die of HIV/AIDS.
This paradigm of life is a product of collective effort nationally, regionally and internationally. It borrowed from the best traditions of the antiapartheid struggle: resistance, social mobilisation and unity. It benefited from the best traditions of the antiapartheid struggle – international solidarity – made up of individuals, governments, communities and organisations, inspired by the idea that life and dignity are a universal human right to be enjoyed by all, irrespective of economic status.
It is for this reason, therefore, that researchers are expending effort and resources studying the social determinants of the epidemic. This is more urgent, given the shifting political economy of HIV infections.
A decade ago, the epidemic was driven by conditions of poverty, deprivation, migrancy and gender-based violence. Today, it has assumed or added other dimensions, including social media, electronic media, reality television and inequality. This challenges prevention strategies to move beyond traditional approaches of above and below the line messaging and condom distribution. To consign HIV to the museum of the history of epidemics, there has to be greater use of social and electronic media, which have created social bubbles where unprotected sex and multiple concurrent partnerships take place. As far as declining knowledge levels are concerned, a study by the Human Sciences Research Council observed that disinvestment in communications by national government has eroded earlier gains as trends show diminishing knowledge levels among significant sections of the youth population. (Add growing gender, interand intra-class inequality into the matrix, and the situation deteriorates further.) In July 2016, South Africa hosted the biennial International Conference in Durban. This was the second time that this conference came to South Africa, the first being in July 2000. As many of the conference proceedings and public commentary showed, the 2016 conference took place under significantly altered conditions. The imagery was that of life and hope.
There was greater coherence and cooperation between government, civil society, the private sector, international agencies and other role players. The context in which the HIV epidemic continues to expand in countries around the world is one of growing polarisation between rich and poor ... and increasing social inequalities that seem to be an integral part of globalisation based on neoliberal economic policies.
HIV continues to be a major global public health issue, having claimed more than 35 million lives thus far. According to the World Health Organisation, there were approximately 36.7 million (34 million to 39.8 million) people living with HIV at the end of 2015 with 2.1 million (1.8 million to 2.4 million) people becoming newly infected with HIV in 2015 globally.
South Africa is home to the largest concentration of people living with HIV anywhere in the world. When it first emerged, few could know how the epidemic would evolve, and fewer still could describe with any certainty the best way to combat it. The estimated overall HIV prevalence rate at the time of writing was 11.2% of the total South African population. The number of people living with HIV was estimated at 6.9 million in 2015. For people between the ages of 15 and 49, an estimated 16.6% are HIV positive.
The message is clear: social partners in southern Africa should intensify efforts to turn the tide against HIV and TB. They should move beyond biomedical science and investigate the social science, that is, reallife experiences that increase vulnerability to HIV infection. They should ask and seek answers to questions such as why infection rates increase even among the most educated and upwardly mobile people. What social pressures affect adolescent girls, young women and the middle class to the extent that they readily exhibit risky sexual tendencies, much like the least educated and marginalised population groups that are exposed due to sexual violence, poverty and intergenerational sex? Is it some false sense of invincibility that “this won’t happen to me”, or “surely this banker can’t be HIV positive”, or “let us just enjoy sex unencumbered by intermediaries like condoms”?
Social and behavioural scientists need to study this phenomenon to realign national strategies in response to what statistics tell us about incidence and prevalence trends.
Evidence-based studies are urgently required to develop a thorough understanding and response to challenges presented by the growing use of social media. Deeper insights into the dynamic use and misuse of social and electronic media will help policy makers and stakeholders turn tables, effecting positive behaviour change through the same platforms that are currently used to promote risky lifestyles.
Zero infections remain our goal. An AIDS-free generation is possible. Bold steps need to be taken, however, by individuals, organisations, communities and stakeholders to spread the message – and to live by it – that safe sex is the way to go; and knowing one’s status is a prerequisite for unprotected sex, in addition to faithfulness.
STAR POWER A contributor to the book, the musician Sir Elton John, is presented with an award during the International AIDS Conference in Durban last year