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Mbulelo Mzamane's paper on the contribution intellectuals can make to the HIV/Aids debate appears on this site.
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Condoms are not enough in the HIV/Aids battle
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'Letting Them Die': Why HIV/Aids prevention programmes fail
Catherine Campbell
2003
James Currey, Oxford
Reviewed by Claire Roberts Lamont
As the title suggests, Catherine Campbell’s, 'Letting them Die', Why HIV/AIDS prevention programmes fail, sheds light on the complexity of the HIV/AIDS crisis in South Africa.
A combination of the lack of a unified and coherent national strategy and difficult cultural and social issues has made South Africa an ideal host for the rapid spread of HIV.
The book is a description of a research project in which Campbell was involved. She warns in her introduction that there are some sections, which are heavily academic, and the reader can be lost or discouraged by the lengthy description of the research methodology. The majority of Campbell’s book is written, however, to serve as a guidebook for anyone running or working in a health related programme in a developing country. And some of its bleak assessments of the challenge facing South Africa are of universal interest.
The book concentrates on one HIV/Aids programme to illustrate the point. The prevention programme described here is a high profile and externally well-funded programme in Summertown, a small squatter settlement an hour’s drive outside Johannesburg. It combined peer education and community mobilisation with the goal of reducing the transmission of sexually transmitted HIV infection. The three target groups were commercial sex workers, migrant mineworkers and young people.
In the recent past, it has become clear that individualistic biomedical approaches to social diseases such as HIV/Aids need to be enhanced with programmes that address wider social and behavioural issues. Simply providing condoms and information about how HIV is spread is insufficient for controlling and stopping the spread of the disease. As Campbell indicates, epidemiologists have been successful in connecting social determinants with disease, but not at explaining the processes that underlie them. Interviews with mineworkers, commercial sex workers and young people highlight local reasons why these groups continue to have sex without using a condom and thereby risk a slow and painful death from HIV/Aids.
The mineworkers are aware of how HIV/Aids is spread and know that condom use will prevent them from getting it. These facts exist within the complex circumstances of mineworkers' lives. Mineworkers live in hostels and only occasionally travel back to their families in other parts of South Africa, or Mozambique and Zimbabwe. The mines are dangerous and the work is unpleasant and difficult. Because of the high unemployment rate and lack of skills, men who work in mines are easily replaceable. The incentive for industrialists to improve the conditions of mines, and thereby mineworkers’ lives, is small.
The mineworkers interviewed stated that the risk of getting HIV/Aids was small compared with the risk of death that they faced every day in the mines. Mineworkers suffer from loneliness and having sex "flesh to flesh", without the use of a condom, is a way of creating a feeling of intimacy. Therefore, although mineworkers understand that HIV/Aids is spread through unprotected sex, the context of their dangerous daily existence prevents simple behaviours, such as agreeing to the use of a condom.
"The risk of getting Aids was small compared with the risk of death that they faced every day in the mines"
The survival of commercial sex workers depends on the money they make from selling sex. The social context in which they work and live provides little opportunity to insist that their sexual partners wear a condom. Commercial sex workers are at the lowest rung of hierarchy among African women in terms of advantage and power. Like mineworkers, commercial sex workers face the reality of the sheer numbers of women who are desperately poor and have to cadge for day-to-day existence. If a man does not get what he wants – flesh-to flesh sex – there are many other willing women. An overall lack of unity and high competition among sex workers has made collectively insisting on condom use difficult. Campbell illustrates that despite these challenges, on smaller scales women have managed to support and protect each other. A system of shaming men and supporting each other in doing so has been successful.
Like mineworkers and commercial sex workers, the sexual behaviour of young people is shaped by social and sexual attitudes and norms with constraints that make it difficult to change them. Young people hold on to stereotypical views about gender, trust and relationships, which makes behaviour change very difficult. Despite high levels of knowledge about HIV/Aids, perceived levels of personal vulnerability were low and unprotected sex was common. The study revealed that rape and emotional pressure was characteristic of young people’s first sexual encounter. Young men were pressured to have frequent sex with as many partners as possible. In order for young women to protect their reputations, they stated that it was important to appear unavailable for sex by not carrying condoms.
Parents denied sexual behaviour in young people and it was considered a taboo subject. If discovered, young people were punished for engaging in forbidden acts. These factors operate as barriers for young Summertown residents with even the most sophisticated understanding of HIV/Aids from using condoms and participating in safer sexual practices.
The empowerment of young people in the area of sexual behaviour becomes superficial when attempts are not made to reduce the high levels of poverty and unemployment. Without an attempt to improve the overall context of young people’s lives, the risk of HIV/Aids is simply added to a long list of factors that lead to a short and low quality of life.
It is clear that in all three target groups – mineworkers, commercial sex workers and young people – simply increasing levels of knowledge about how HIV/Aids is spread and providing better access to condoms did not improve safe sexual practices.
The Summertown project, in addition to providing information and access to condoms, used community mobilisation and peer education in an attempt to increase individual’s motivation to perform healthy behaviours. It tried to help people to identify their power to act in ways that protect their health and to teach them the skills to use that power. This empowerment process is a major tenet of health promotion.
The ability for someone to become empowered is limited or enhanced by the extent to which the community and social context offers support for the performance of such behaviours. In a community like Summertown, individuals do not have the power to put healthy choices into practice. As Campbell illustrates, each of the three groups experience unique barriers to putting healthy choices into practice. The attempt to facilitate community mobilisation in Summertown was an attempt to develop social and community contexts that would support individual health-enhancing behaviours.
Peer education is one of the most commonly used health promotion strategies throughout the world-specifically with young people and hard-to-reach groups. Peer education involves training members of groups who live and work in situations that place them at high risk of HIV-infection to disseminate information about sexual health risks and distribute condoms. Peer educators are trained in leadership skills, teaching skills and how to facilitate participatory approaches such as role-plays and dramas to people who may not have high levels of literary skills.
Theoretically the project was sound and given the challenges associated with each of the target groups the method was an appropriate one. However, the measure of the success of the project was whether a reduction of sexually transmitted infections (STI’s) had been achieved after three years. Campbell is clear that the project did not come close to reaching this goal.
Campbell comes to the conclusion that these methods are appropriate especially with the target groups, but that they cannot work in isolation without the existence of a larger comprehensive HIV/Aids strategy. She clearly illustrates the reasons it didn’t work in Summertown. The main reasons that permeate all three projects with the target groups include power issues, funding structure and hierarchy and the lack of a larger supportive national HIV/Aids prevention strategy.
Power issues were a recurring theme throughout her account of the Summertown project. Mineworkers, commercial sex workers and young people all experienced powerlessness in their daily lives. The process of empowering previously disempowered groups was not always a welcome or shared goal. Further, the attempt to gather people from the different stakeholder groups and have them reach consensus was difficult because the scientists, industrialists and grassroots community members did not share equal power. These unequal power relations affected the possibilities for collaboration and reaching consensus.
Gender issues are paramount in the HIV/Aids crisis in South Africa. They played a role in the relationship between mineworkers and commercial sex workers and also between the young people of Summertown. Campbell clearly noted that HIV/Aids prevention cannot occur without addressing the unequal relationships between men and women especially when attempting to change sexual behaviour.
Externally funded programmes which have made up the majority of South Africa’s prevention schemes, written by foreign academics, are heavily scientific and based on successful programmes in Tanzania and Uganda. The Summertown project materialised in much the same way. After being funded, the programme was handed to local constituencies to run without them fully understanding the context and purpose required to carry them out. Further, the fit between the generically designed programme and the community of Summertown was not a good one. Assumptions in the proposal about the nature of Summertown resulted in over ambitiousness in the commitments of the stakeholders, scientists, industrialists and grassroots community members. Project workers were frustrated, overworked and the communication with the scientists was not always easy. The distance in experience and the perspectives "on the ground" and "in the office" was great. It made communication between the two difficult.
Because of the slow movement of the South African government to provide leadership and support to prevention schemes, almost all of the HIV/Aids programmes are foreign funded. Strong and decisive leadership in Uganda, Senegal, Thailand, Brazil, have led to success in prevention and management of HIV/Aids. The Summertown project, like most of the HIV/Aids programmes in South Africa, has had to function outside of a national structure. The Summertown local government was proactive and supportive of the project, but the lack of the national government’s direction and its confusion over the origin of HIV/Aids has contributed to the confusion that exists over how HIV/Aids is spread, treated and contained.
The Summertown project used peer education and community mobilisation to prevent HIV/Aids. Campbell clearly indicates that although this is an important project, a comprehensive HIV/Aids strategy must include approaches on three time scales. The long term includes macro economic development, which will improve people’s autonomy and ability to make health-enhancing choices. The medium term, which includes projects like Summertown, which is to change norms of sexual behaviour through community level approaches, and short term which is through the aggressive detection and treatment of STI’s.
Campbell leaves the reader with the clear message that without work on all three time scales and levels, work on any one of them will have little success. Perhaps the commitment the South African government has recently made to not only provide antiretroviral treatment, but to focus on HIV/Aids efforts that individual projects make will contribute to an overall coherent scheme and the world will start to see the rate of HIV/Aids transmission drop.
Claire Roberts Lamont worked on an HIV/Aids prevention programme at the Trevor Huddleston Memorial Centre in Johannesburg. She is currently a health promotion specialist for Shaftesbury Homes in London.
