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…
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