If you want to feel hopeful about HIV/Aids, don't talk to a doctor at the end of an 11-hour flight back from South Africa. It wasn't so much the high death-rate that depressed her: she specialised in seriously ill patients and was used to them dying. It wasn't even the disaffection of the other medical staff: seven doctors had resigned in her hospital in two weeks. I checked the vacancies list at another hospital in the region: they are currently missing 14 senior medical officers and seven principal medical officers.
What really got her down was that HIV was still something that nobody wanted to know about. In South Africa, both HIV testing and antiretroviral (ARV) treatment are free, yet the take-up remains extremely low. When more than a third (39.5%) of pregnant women test positive for HIV, you'd think it would be hard to be in denial, but this is the case.
I had been taken to South Africa by Christian Aid in order to visit one of their partners, the Thandanani Children's Foundation. Everything I saw was admirable: the foundation supports more than 2000 Aids orphans in the settlements and townships around Pietermaritzburg. It works intelligently and humanely, and needs our money. But it is well aware that there is little being done to stem the flow of orphans coming on to its programme. It hopes to fund home visits by an HIV-tester, since the present testing centres have acquired the reputation of the old clap clinics in the UK, but even this would depend on consent. When a couple of years ago the South African government attempted to quantify HIV infection through an anonymous sampling, 45% of those asked refused to take the test.
As a result, nobody has any real idea of the prevalence of HIV infection. The government reckons it is one person in 10 across the whole of South Africa, and one in six in KwaZuluNatal, where I visited. But this is the proportion of the total population, infants included, so one can reckon that about a third of adult women in KwaZuluNatal are infected, though fewer men.
Ah, yes, the men. Men are the key to controlling the spread of HIV/AIDS, and this is why it still hasn't been brought under control. A paper in the Journal of Acquired Immune Deficiency Syndromes speaks of "the shift toward a female-dominated epidemic". Whereas deaths of young adult men have doubled in the Aids decade, deaths of young women have quadrupled. The journal traces this, in part, to "exclusive male negotiation of condom use", a technical use of the term "negotiation" that I hadn't come across before, ie one that carries none of the word's usual meaning. In essence, the men most likely to be HIV-positive are the ones least willing to use condoms, pretty much by definition. They have not been persuaded to find out their HIV status; nor are they convinced about treatment that can inhibit the development of Aids.
One thing is obvious to them, though: the younger your sexual partner, the smaller the risk that she has been infected. It seems that there are men around ready to act on this information: of the 389 women who turned up at a rape crisis centre in Pietermaritzburg over a 15-month period, 42% were under 18.
Of course, the opposition to HIV/AIDS testing and treatment hasn't just prevailed among the poor. When I was in South Africa, I heard people defending Thabo Mbeki's feet-dragging over the introduction of ARVs. He had been right, they said, to focus more on poverty, since this was the chief factor in how long those infected with HIV survived. Indeed, it has been shown that the effectiveness of ARV treatment is undermined by poor nutrition, something that is alarming those working with HIV/AIDS in Zimbabwe at the moment.
Nevertheless, a new study, also featured in the Journal of Acquired Immune Deficiency Syndromes, calculates that the delay in introducing ARVs led directly to 330,000 needlessly premature deaths. And a recent article the Lancet reckons that universal testing could reduce HIV infection by 95%. The treatment works, as has been shown in neighbouring Botswana, for example. The difficulty is persuading those most likely to be HIV-positive to find out, then do something about it.
In southern Africa at least, HIV/Aids remains a disease of the poor, the hungry, the aimless, and the unfortunate women they come in contact with. If any improvement in the mortality rate is to hoped for, the authorities must change HIV/Aids from the something that is referred to only euphemistically – "this terrible disease that is affecting so many of our people" – to a condition that can be named, and treated, and no longer feared. It is a balance to strike: to reduce the fear and stigma so that people seek testing and treatment, and yet keep people fearful in order to stop them becoming complacent about the condition and the behaviour that spreads it. There are few governments around at the moment that could deliver such a combination of medical, economic, and moral support and guidance. Perhaps, one day, South Africa's will be one. But for the moment, as I said, if you want to feel hopeful about HIV/AIDS, don't talk to anyone who has just come from South Africa, and I suppose that includes me.
