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Reporter’s Notebook: Cultural Taboos Around Sex Feed AIDS Epidemic

BY Admin  February 23, 2009 at 4:30 PM EDT

Grave diggers in Soweto

For a very long time, South Africa was a very conservative place. In this corner, Calvinist Afrikaners, gravely frowning at revealing clothing, too much drink, depictions of sexual material in popular culture. Over here, the British Government and its established Church of England, which discouraged all but the most conventional sexual mores. And most numerous of all, black Africans and the wide array of Protestant denominations they professed, many native-born churches supporting a very buttoned-down brand of Christianity.

Even during the resistance to apartheid, leaders who spent long years in exile could easily be considered straitlaced. Sophisticated and well-travelled, spending big chunks of their adult lives in the Eastern Bloc and the decadent West, many were still mission school kids who learned their lessons well and frowned upon multiple partners, divorce, homosexuality, and pornography.

As in so many parts of South African life, the country has had to come a long way in a short time. In the final analysis it may not matter all that much whether the country comes willingly or is dragged kicking and screaming.

The lives of millions are threatened by a disease very efficiently transmitted by sex. This year, more than a thousand South Africans a day will contract the HIV virus.

Sex has been decoupled from love in a fundamental way. Worst of all, the discussion of sex has been decoupled from death, which daily makes the problem worse.

All the way from South Africa’s minister of health in a beautifully appointed executive suite in the Parliament buildings in Cape Town, to a married woman in her thirties on a garbage strewn produce market in the teeming Soweto township, the message was often the same, even if the elements were presented in a different order:

Men want sex from women.

Men don’t want to use condoms.

Men refuse to check their HIV status.

Women can’t refuse to provide sex to men on whom they rely.

Both men and women commonly have multiple sex partners, either inside long-term relationships or in transactional sex (for money, food, protection).

See number two. When women told me the men in their lives refused to be tested, and refused to wear condoms, I often followed up with the very simple question, “Even if it means he ends up dying and killing you too?” Their answer, just as simple: “Yes.”

Policymakers high up on the country’s organizational chart struggle to find a message that strips the discussion of AIDS of shame, judgment and guilt. They openly strive for HIV status to become an unremarkable medical fact as easily produced as a cholesterol level or blood pressure.

The early messages about HIV and AIDS tried to scare people into doing the right thing to stay safe, and since there was no cure instead found the strategy had backfired. Sexual behavior didn’t change, and people avoided finding out their HIV status because it might only mean sure death with no recourse and no options for treatment.

You might see the wisdom in that strategy. Stop making AIDS scary. Make HIV status a thing somebody might want to know in hopes they could get on retroviral drugs and save their own lives along with those they have sex with. But while pursuing the goal of detaching HIV and AIDS from moral conclusions about decision-making and behavior, they might have also thrown out something unintended: love.

The people of South Africa have been bombarded for 20 years with public health messages on the radio, TV, billboards and in print about every facet of the HIV virus. The spread of the virus, its trading among sexual partners and its passage out to radiating memberships in wider sexual networks, the particular threat to pregnant women and newborns are all old hat.

Even the presidential terms of Thabo Mbeki, who questioned whether HIV causes AIDS, didn’t slow down private sector and non-governmental efforts to get the word out.

All this has happened at a time when hundreds of thousands of people were dying of AIDS without ever even having a diagnosis, and while South Africa was becoming the country with the single largest HIV-positive population on earth.

Yet, men still seek out multiple partners. Women still concede to unprotected sex with men whose viral status is unknown. Men still condemn their own consequent children to short lives of suffering and death.

That people are capable of callous disregard for others is not new. That men are capable of cruelty to their own wives and children is not new. I guess it’s the scale that’s puzzling. The existence of so many people who are willing to roll the viral dice, repeatedly, and each time hope everything turns out OK.

That’s why you’ve got to remove the stigma, I was told. A man who offers to wear a condom will immediately be suspected of HIV infection and found unsuitable as a sex partner. A woman who demands her partner wear one will be seen as making an accusation of infidelity, or making an admission of infidelity, and neither is a palatable choice. So millions carry on doing what they’ve been doing, with predictable and disastrous consequences.

Some have placed their hopes in treatment, rather than prevention. Getting people to change their behavior hasn’t worked, they reason, and now that antiretrovirals make HIV infection something other than a death sentence, let’s show the country models of living and thriving with HIV. There’s an appealing logic there: Build down the stigma, build down the fear, encourage testing and then put the HIV-positive population on the drugs that will save their own lives and make them less contagious at the same time.

Not everyone’s so sure. The medical director for a large employer told me you’re never going to medicate your way out of this crisis, and that changing behavior was the only way to defeat HIV in the long run. Both approaches make sense, but in different time frames.

One school of thought says the house is on fire and we don’t have time to sit down and have a family meeting about how to throw water on it and get out alive. The other says unless we stop doing the same things we may get today’s fire out, but the next place we move is going to burn down and so is the one after that.

For our upcoming series on AIDS and tuberculosis in South Africa we interviewed John Molefe, producer of one of the longest-running dramatic series in South African television, “Soul City.” The show deals with the realities of black daily life in South Africa, and is guided to a remarkable degree by polling and social science research in crafting its themes and story lines.

Recently Molefe decided to throw the weight of the show behind the One Love campaign, a national multi-media effort to encourage having a single sex partner.

Molefe said it isn’t charity, and though he believes in One Love’s goals, the alliance isn’t entirely altruistic. The tension around the sexual behavior among his countrymen is driving conversation and debate among audience members and confronting his country with life or death choices about the future.

For one of the creative minds behind a hit show, being at the center of controversy is both the right thing to do and an extension of the way the show has positioned itself since its debut in the late nineties.

Across the country from the leafy Johannesburg park where Molefe and I sat down for a talk, Rebecca Hodes of the Treatment Action Campaign predicted One Love won’t work. As much as she found its goals admirable, Hodes said simply telling people something over and over again won’t make them stop as long as campaigns like One Love don’t address twin truths about the spread of HIV in the country.

One problem is the heavy promiscuity among the young who believe they will be the exception rather than the rule in their unsafe sex practices. Another is that teenagers and young adults are among the most economically disadvantaged and powerless of all South Africans, and any campaign that ignored the transactional nature of sex in poor communities would not change anyone’s behavior.

On the one hand. On the other hand. What people do is making them die. On the other hand we can’t get them to stop doing it. We are very afraid of the spread of a disease, so we tell people how to protect themselves. On the other hand, if they don’t protect themselves we’ll give them medicines to keep them alive. Male dominance in South African society undermines women’s ability to protect themselves from the HIV-positive men in their lives. On the other hand, a traditional source of male power-their children-have their lives put in jeopardy by paternal irresponsibility.

Sex and death are now intertwined in South Africa to create a hellish problem. One Saturday morning at Soweto’s main cemetery, watching families bury people in their 20s and 30s is enough to break even the hardest heart. Wouldn’t you do what you could to avoid … this?

What several people told me over two weeks of reporting was that life has been appallingly hard for a very large number of people in South Africa. When you are short of money, short of food, short of work, and short of education year after year, taking new steps to protect your life and make it a long one just doesn’t seem the same kind of priority it was in the 80s and 90s, when AIDS burst upon the scene in Europe and North America.

Is that really it? Are South Africans unwilling to do what it takes to save their lives because they’ve figured their lives really aren’t that valuable? Please watch my upcoming series of reports on the NewsHour, starting in March. And watch the Online NewsHour for more material from the recently completed reporting trip.