A Mind-Shift is needed to win the war against HIV and AIDS

zilleOn Saturday night, I attended a fundraiser for a children’s hospice called Iris House.

It is an NGO that cares for severely disabled and terminally ill children, and supports their families. At our cabinet meeting last week, we had agreed to lease, for a nominal amount, a dilapidated structure at one of our health facilities to Iris House, to assist them in their work.

The depth and effusiveness of their gratitude for the use of this small derelict house made me reflect, in some embarrassment, on how little government does for organisations that do the work we should be doing to support people who are unable to support themselves.

And that, inevitably, brought me full circle to thinking about how many billions we pour into treating preventable conditions, while angry activists, who have built whole industries on these issues, attack us for not doing enough.

Inevitably, I reflected on one of the world’s biggest conferences – the 20th International AIDS Conference – that was recently held in Melbourne, Australia.

The conference drew over 14 000 delegates from across the globe. Different sessions took place every hour in 20 venues, every day for four days. It was a conference of staggering proportions, attended by just about every AIDS expert in the world.

One of the main concerns expressed in media reports on the conference, was that AIDS might soon be considered “manageable” and would cease to attract the billions of dollars in funding that has been poured into research and treatment over two decades.

When it comes to state programmes, South Africa – and specifically the Western Cape – are at the forefront of global efforts, particularly in treatment and the prevention of mother-to-child transmission.

Many of us think that this is the hallmark of a successful AIDS policy. But, as long as the incidence of HIV infection keeps rising, it is in fact a reflection of its failure.

According to a report by the Human Sciences Research Council (HSRC) released earlier this year, over 400 000 new infections occurred in South Africa in 2012. This now ranks us number one in HIV incidence in the world, with females experiencing far higher rates of infection than males.

In the report, the HSRC chief executive said this situation “requires a rethinking of conventional approaches of HIV prevention towards strategies that address the underlying socio-cultural norms in the affected communities.”

I have searched the media reports in vain for any indication that the Melbourne AIDS conference engaged in any form of “rethinking of conventional approaches” and tackling behaviour change. Provincial Minister Theuns Botha, who led the Western Cape delegation, confirms this issue was conspicuous by its absence.

Everyone involved in the fight against AIDS in South Africa knows the slogan: “Talk About It”. For the past two decades we have spoken about every possible dimension of the disease, except the one that matters most: How to “address the underlying socio-cultural norms” to which the HSRC chief executive referred. We have, fortunately, beaten much of the stigma associated with AIDS, but no-one dares confront the stigma of talking openly about the health crisis occasioned by multiple, concurrent sexual partners and inter-generational sex.

This topic is the last great taboo in the fight against HIV and AIDS. Most “Western” researchers only mention it in whispers, presumably for fear of being labelled “racist”.

This, despite the fact that a behaviour modification campaign devised and led by Africans, resulted in the most successful and cost-effective campaign ever waged against HIV and AIDS. It should have formed the foundation of the world-wide battle against this disease.

In 1989, Uganda had the highest HIV infection rate in the world, with a rural infection rate of 18% and an urban rate of 30%. Their government then embarked on a massive public awareness campaign to change the underlying behaviour responsible for the rampant spread of the virus: multiple concurrent (or overlapping) sexual partners, and inter-generational sex.

Driven by Ugandan women, the “zero grazing” campaign focused on fidelity. It urged couples to stay faithful to each other and avoid multiple partners. The campaign wasn’t just aimed at high risk groups like truck drivers and prostitutes, but recognised that ordinary people in ordinary relationships were at risk.

Perhaps most importantly, women became empowered to walk away from unfaithful partners and shame those who continued with sexual affairs. This shift in attitude and power is what researchers began to describe as the “invisible cure”. They had to use code words.

A decade into the campaign, Uganda’s infection rate had dropped by almost two-thirds, making it one of the most effective health campaigns in history.

It is important to note that the “zero grazing” programme was developed by Ugandans as their own AIDS response before Western experts stepped in, and before the AIDS industry had even started.

If we had followed the Ugandan example we would have beaten the disease long ago. Unfortunately, Uganda was soon following the AIDS “experts” in the rest of the world.

They abandoned the “zero grazing” campaign in favour of the type of messaging that shifts responsibility away from the individual, to the state.

It’s the messaging we’re used to – condoms, testing and drugs – and it’s the type of messaging that international donors are comfortable paying for. (Any price is better than the stigma associated with discussing the need to change sexual behaviour, and running the risk of being labelled racist).

As a result, the Ugandan success story has suffered a reversal, and infection rates are on the rise again. This trend coincided with the availability of more effective ARVs – a factor that has lulled people into a false sense of security around the virus. In fact, the more money was spent, the more the successes of the fight against AIDS in Uganda were reversed.

Uganda’s behaviour change programme cost around $18-million a year. In contrast, the USA President’s Emergency Plan for AIDS Relief (Pepfar) has spent more than $1.7 Billion in Uganda on medications between 2005 and 2012. During that period, HIV infections in Uganda started moving up again, from 6.4% to 7.3%.

In South Africa, home to some of the world’s foremost AIDS expertise, we upheld the taboo on the “behaviour change” debate. Instead, like the rest of the world, we threw more and more money at the problem, with the result that we now have the world’s highest infection rate, and rising.

In February this year we learnt from then Finance Minister Pravin Gordhan’s budget speech that the national government had spent R41 billion on HIV and AIDS programmes over the past five years. The budget for HIV and AIDS programmes over the next three years is R43.5 billion. And this is just public spending. Once you factor in donor money channelled through NGOs, you begin to get an idea of the size of the industry.

AIDS has become a treatable, chronic disease, but it comes at a massive cost. And in developing societies, that cost goes far beyond the billions we spend on treatment. Ours is a massive opportunity cost. This refers to the essential health programmes we can’t afford because we are spending so much money treating HIV, which should be an avoidable and preventable condition.

Many people try hard to “manufacture” outrage when I speak about trade-offs in decisions about how to spend our health budgets. But we’re a developing nation and we need to face this debate honestly.

Unless we overcome the taboo and address the core problem of multiple concurrent sexual partners, we won’t beat the disease. Instead we’ll continue to spend billions on a preventable condition when many thousands of unpreventable illnesses and disabilities are neglected, or even ignored.

In the same HSRC report mentioned earlier, one third of young girls aged 15 to 19 reported being involved in age-disparate relationships involving a sexual partner more than five years older than they were.

Many people believe this is none of the state’s business. But in a country with so many health needs, unsafe sex is not a personal matter. It costs the state billions, deprives others of affordable treatment for a variety of debilitating illnesses, and costs lives.

In this situation, surely a government can expect individuals to take responsibility for establishing their HIV status, if the state provides the opportunity of a free, annual HIV test? And then, depending on the result, surely it is not too much to expect people to take personal responsibility for preventing transmission or remaining HIV-free themselves?

And surely society has the right to regard the knowing transmission of HIV as a serious crime?

Every time I raise this question there is an outcry. While it is not always easy to prove intentional or reckless infection, criminal prosecution for knowingly passing on HIV occurs in many other democratic countries.

In a high profile case in 2012 in the USA, former wrestler Andre Davis, was sentenced to 32 years in prison for having sex with women without telling them he was HIV-positive. The mother of his two children forwarded his test paperwork to his other girlfriends.

People have been convicted in more than 30 states in the USA for knowingly infecting others with HIV. Other countries with legal precedent in securing convictions for HIV infection include Netherlands, Poland, Australia, Finland, New Zealand, Russia and the United Kingdom. Canada reportedly views the act of knowingly infecting someone with HIV as first degree murder.

In Sweden, failure to comply with their HIV disclosure obligation before unprotected sex, can result in charges of attempted aggravated assault and a prison sentence, even if the virus is not transmitted.

South Africa is about to establish its first precedent on the knowing transmission of the virus as well. This will be big news in a country where we run a mile from any mention of personal responsibility; and where adult males having sex with young females has become normal.

In 2011, a group of three Durban women got together to speak out against a man who had infected them with HIV while aware of his positive status. Three years later, one of the women has finally set the wheels in motion to launch a civil lawsuit against him. Cindy Pivacic – now an AIDS acitvist and author – plans to also follow up the civil claim with a criminal charge. This will be the first of its kind in South Africa, and many people will be watching it with keen interest.

Because, if we do not redirect our resources to preventing preventable conditions, there is no limit to what we could spend treating HIV without any guarantee that the numbers will come down. In fact, on past experience, the opposite is more likely.

We must start by breaking the stigma associated with the only effective preventative measure yet discovered: Personal Responsibility.

Helen Zille

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