African Perspectives on
South Africa Discussion
than twenty individuals participated in the discussion,
including representatives of government, media, research
institutes, business, religious communities, and NGOs working
on HIV/AIDS, youth, and other issues. The topic was U.S. and Western Policy Responses to HIV/AIDS
in Africa and how these responses are perceived within Africa.
initial discussion was around the question in
what ways is it necessary to address the HIV/AIDS epidemic in
Africa differently from HIV/AIDS in the rest of the world?
was a far-ranging discussion and many areas were addressed but
the key points that emerged were the
Very high infection levels in the SADC (Southern
African Development Community) region
The complex issues of gender, poverty and
range of questions supplied for this forum guided the
discussion and the discussion was an attempt to link the
general themes of the questions.
Although each specific question was not dealt with on
its own, each issue was addressed. Most of the panel had received the discussion themes
beforehand and were, to some extent, prepared to address the
range of issues. The
diverse experience and understandings of the group also led to
Recognition of the problem
was agreed that South Africa displays one of the HIV/AIDS
paradoxes: most of the population is aware of HIV/AIDS and the
manner and nature of its spread, but this has not translated
into effective programs and policies or into any sustained and
effective behavior change.
are very good explanations about why we have such a high
Since the development of the National AIDS Plan in
1994, we have had very clear understandings about migration,
housing, societal factors and poverty and their contribution
to the spread of HIV in Southern Africa.
now have understanding of the Class C virus, which is the most
common variant of the virus in this region, but we need more
research on why it is regarded as being so highly infectious,
and why it should be the most prevalent form of virus here.
We are finding ways to research and develop an
of this information and twenty years of experience with
HIV/AIDS in South Africa and the rest of Africa, we are still
confronted by the failure of governments to speak openly about
HIV/AIDS and to provide effective leadership.
most important cause of why the epidemic is so serious in this
region is a complete failure by governments to openly
acknowledge the seriousness of the epidemic - to speak openly
about it,” said one participant. Included is the failure to address the ongoing stigma and
prejudice and to recognize the links between gender, domestic
violence and abuse as part of the pattern of infection.
to see stigma as the central pin around which all our efforts
need to turn as opposed to seeing stigma as just something
that we add on - I think it’s the pivotal factor that makes
HIV different in this region,” said another participant.
Threat to investment and the economy
is now recognized that HIV/AIDS is a very complex issue and is
integrally linked to wider social issues such as poverty,
security (both domestic and national), migration, gender and
point was made that unless there is a coherent position on
HIV/AIDS and effective measures to deal with it long-term,
large-scale investment would be threatened.
There must be more work on the impact of the disease
and on getting more reliable statistics.
future of the country is at stake if the economy is destroyed
and there must be support for the development of a viable
economy, job creation and the development of a skills base.
This requires that general agreement be reached on the
nature of the problem and on its potential scope of impact.
research and bad statistics compound the issues and feed into
the denial - it is essential that we make clear decisions
about surveillance and how we will obtain and use the
must have good statistics and stop debating whether the
statistics are right or wrong - we've go to reach a point
where we say the statistics are right and we will take on and
deal with the issue and the impact.”
with poverty alone is insufficient.
It is essential to see that, in Africa, AIDS is fed by
and feeds into a wide range of complex issues in which race,
class and culture play a crucial role. “There are a lot of cultural beliefs that we need to look
at and start saying - what is the impact of HIV on these and
how are we going to change that, without breaking down these
norms and values.”
Education for youth - in and out of school
in South Africa is characterized by a lack of HIV/AIDS
education in schools,
by gender inequality and non-consensual sex,
by stigma and denial, by structural determinants and by
cultural and racial factors that contribute to the
vulnerability of communities and particular groups of people.
Youth out of school are also not being reached
effectively. In order to have an impact on this epidemic and
the future of the country, new youth programs will be needed.
Sexual behavior - multiple partners and promiscuity
people have more partners in sub Saharan Africa.”
you talk about multiple partners we really have to look at the
evidence that underlies that …”
wide-ranging discussion about sexuality and sexual practices,
there was some debate about the notions of ‘African
promiscuity’ and whether it is true that Africans have a
tradition of multiple partners.
Whilst it is true that for the levels of infection to
be so high there must be high levels of sexual activity, some
participants felt that these had to be viewed in the light of
historical factors such as migration and inequality.
Others felt that there was a clear breakdown of social
cohesion and social norms and that there is a pattern of
multiple partners and a generally high level of sexual
notion of “sugar daddy's” was also described as
being simplistic and unhelpful and deflecting away from the
real issues. But
it is also recognized that any open discussion of this in
society is difficult because of the sexual taboos, the early
initiation of children into sex, and the failure to create a
climate in which people feel safe and able to talk freely
about sexual concerns and behavior.
It was recognized that the high levels of STDs in the
society are indications of a pattern of sexual behavior that
increases vulnerability to HIV infection.
behavior pattern and vulnerability of people to infection
applies throughout the SADC region.
Vulnerability of women and particularly young girls
massive inequalities that women experience within
relationships makes it very difficult for them to protect
themselves against HIV.”
particular vulnerability of women was frequently highlighted
with women's risk of infection being higher than that of men.
The lack of social support for women leaves them in
abusive relationships and their social and economic position
makes them particularly vulnerable. Young girls are vulnerable to the sexual demands of older men
and, as they slide into poverty, they're being forced into
early sexual income-generating behavior.
Hope for an AIDS-free South Africa
have to think, as a starting point, of what it is going to
take to have an AIDS-free society.”
was discussion around how it might be possible to develop
programs and interventions that could make people have a
hopeful response to HIV/AIDS.
People must be able to talk about an AIDS-free South
Africa as a real possibility.
Our thinking has to move beyond catastrophe, and in
looking at the determinants and co-factors see where it is
possible to make effective interventions that can develop a
response that is proactive rather than reactive.
must move beyond denial, and find a way to re-position AIDS so
that there is a sense of urgency and an aggressive response.
This means that the communication about AIDS and what
is possible must be improved and that a change needs to
develop through a greater commitment to the NGOs and
Role of Religion
the time of Apartheid, a lot of fight came from the direction
of the Ecumenical Movement … and here is a challenge where a
religious institution could focus.”
recognized that the role of organized religion during the
Apartheid era was largely one of challenge and confrontation
in the face of the oppression in the country, but that this
voice is now largely silenced.
There was also great debate during Apartheid by
scientists, social theorists and other academics and this
voice is also now muted and ways must be found to re-energize
the response of the church as well as fostering academic
research and debate.
Old debates and new solutions
started working in AIDS in 1992, and I've been hearing these
discussions since 1992 … we must try and look forward.”
point was made that we have been through these debates before
and that we need to focus our thoughts on asking why we have
been unable to address the epidemic when there exists a good
national AIDS Plan
Why is it that we never seem to move on from
identifying the problems?
It is easy to identify problems, but they often
overwhelm us. There is a need to become far more focused and move out of
the paralysis. We
need to revive the partnership and ensure that we
identify key areas for interventions.
know what drives the epidemic in Africa, but the response has
frequently been framed in First World epidemic terms and this
has created a narrow public health response.
The phrase that AIDS is “more than a health
problem” must be translated into a meaningful way to frame a
wider African response. Priority
areas could be increased STD treatment, policies for orphans
and people living with AIDS (PWAs) and treatment.
Africa is not one country
“The epidemic is going to
manifest differently in every single part of the world.”
must also be recognized that there are great differences
between African countries and between the epidemics and the
responses to the epidemic.
It is not necessarily the case that what has worked in
some African countries will translate to other areas.
The epidemic manifests itself differently across the
world and there are different triggers.
is an important point for foreign governments and funders to
take note of: formulaic
responses do not address local needs - and successful programs
elsewhere should be re-implemented with caution.
Patriarchy and the role of men
real thing that’s driving AIDS boils down to the fact that
we have a culture that is male dominant … the people who
control our lives in every respect.”
role of men in society and in the efforts to combat HIV/AIDS
is crucial. The
work of King Zwelathinini
-- both as a monarch and leader and as a man in taking AIDS
seriously and finding ways to address it -- was applauded.
South Africa has a male-dominated culture despite the
rhetoric of equality and empowerment of women.
Men are the traditional leaders in society, and they
take a leading role in perpetuating dominant cultural and
social traditions and responses.
They have immense control over the lives of women.
must be ways to focus on the role of men – as fathers and
partners in this epidemic – and to ensure that they are part
of the prevention and care process and also part of cultural
and social change.
ways in which young men are initiated into social roles and
stereotypes needs to be researched as well as how it would be
possible to make significant changes.
HIV/AIDS is likely to have a dramatic impact on
households as well as on the traditional roles of men in
Racism, culture and inequality
time we come up with what's being done and what's not being
done, it brings out the racial divisions that we pride
ourselves on having conquered.”
is a serious concern in HIV/AIDS prevention and care. HIV/AIDS feeds into many social stereotypes and there is a
pervading belief that it is black people who will be infected
and that other races will not.
This fuels racism and blocks any serious discussion as
to how cultural practices fuel the epidemic.
There is the continuing question of “who speaks for
whom” and the ongoing division of HIV prevention along
racial and cultural lines.
We need to learn how to be a really non-racial and
multi-cultural country and in this we could look to other
countries, though it was believed that the USA and European
countries have still not effectively addressed race, class and
of these issues – culture, racism, poverty, patriarchy,
violence and crime – significantly predate the HIV/AIDS
epidemic. But the
epidemic has given new impetus and new categories of meaning
through which to debate these issues and find solutions.
Globalization and the world economy
are unequally integrated into the world economic system and we
are being forced to accept sets of rules which enhance and
entrench that inequality.”
have seen the incredible impact of globalization in terms of
preventing and limiting our access to treatment in developing
saying that there are particular features of the “African
epidemic” and of the South African epidemic, it is also
recognized that South Africa and Africa are tied up in the
global economy. They
are part of the world economic system and the macro-economic
policies that are decided elsewhere have a direct impact on
the economic and political future of the country.
is crucial that we understand these linkages, the role of the
world economic system and our place within it, for this
relationship has a direct and dramatic impact on the fiscal
austerity, on cost effective or affordable treatments and on
the availability of drugs and vaccines.
Development and the role of government
do we distinguish what we address centrally, what do we
address locally and the development framework in which we have
to do this?”
linkages between health and development challenges need
greater understanding and research.
For example: How do effective programs get implemented
in a country in the midst of developmental and political
change? What is
meant by a development framework?
And how can the AIDS response be decentralized to a
At present, the policy and the plans are directed from
Pretoria to a large extent and there needs to be
prioritization for local level initiatives.
This would be in line with the World Bank's program of
must be integrated into all programs, such as by enabling
frameworks for local government and the development of a full
range of services for local communities.
Decisions on implementation and sustainability must
also be firmer and better developed.
management of the disease and its various ramifications is
crucial and this management extends into policy, housing,
education, treatment and support.
Programs and research
the end of the general discussion period there was a rough
categorization of the discussion into areas that donors could
consider funding as well as research areas that would need to
be funded and explored.
Section 2: FOCUSED AREAS FOR
number of views were expressed about how specific donor
support could be accessed for specific programs or
was concern that the same categories and the same problems
should not be raised and that new ways of accessing funding
should be sought,
Donor agendas and strings attached
is concern that donor programs are being driven by the needs
and agendas of the funding agencies and foreign governments,
rather than by assessments of local expertise, conditions and
often have fairly rigid ideas about how things should be done
based on technical frameworks and time lines.
ways of accessing funding should be sought.
This could be through appointing strong national NGOs
to distribute funds, through private sector boards as well as
through the government, but with clear controls over
Fund activities in the National
could be possible to fund the South African National AIDS Plan
(NAP) much more directly, and to look at an integrated
response that brings together the diverse groups working in
the field. The funding system through government needs to be
overhauled so that the funding is channeled more effectively
and efficiently. There
was some consensus that the Strategic Plan 2000 - 2005 was
generally a weak document.
the funding is not channeled through government, then other
ways for monitoring should be found.
It was also suggested that funding should be in line
with the NAP and that direct funding to governments should not
occur if the government was showing a fundamental lack of
commitment to taking the epidemic seriously.
was made that foreign governments expected African countries
to address the epidemic in particular ways, but the US, for
example, still has discriminatory legislation concerning
travel for PWAs. Said
one participant, “It's almost like we are looking to America
to give us support and human rights and yet they have huge
travel restrictions on people living with HIV.
It needs to come up quite proactively that we cannot
look at them as models of human rights.
That needs to be looked at from their side as well.”
role of consultants was discussed at length.
It was felt that consultants could undermine a national
response as they blocked local capacity building and came with
fixed donor agendas. It
was also felt that consultants could bring some neutrality and
technical expertise and that they were a valuable resource.
Large donations are often viewed with suspicion,
especially the timing, which is often seen as being
politically expedient for the donor.
There must be partnerships and donors must have
The same projects or type of projects should not
be funded over and over.
Duplication needs to be addressed.
There is a great deal of waste and there needs to be
far stronger regulatory mechanisms and greater NGO and
government accountability. There should not be 'double
Funding should be made available over longer
contracts are unacceptable as too much time is spent looking
for the next cycle of funding.
With long term – 4 to 5-year contracts - there should
be strict annual reviews.
Guidelines should be developed for donors.
There should be an international index of HIV/AIDS
commitment and the allocation of resources should be
commensurate to the size of the problem.
The consequences of funding programs must be
example, some PWAs are prepared by donor funded programs to
disclose their status only to find that there is no follow-up
There are some very positive experiences of
funding and these have allowed for latitude in learning as
well as for engaging in debate.
major area of concern for South Africans is the access to
includes access both to mother-to-child-transmission (MTCT)
treatment as well as access to the range of anti-retroviral
drugs. Whilst it
is well acknowledged that there are few of the necessary
structural features in place to support extensive treatment,
this should not hold up treatment for people who could utilize
policies are hindering access to treatment.
The role of the U.S. Government in denying access to
treatment needs to be fully explored in terms of their support
for the interests of the pharmaceutical companies.
In the words of one participant, “a foreign
government was allowed to intervene actively in the workings
within a country - in trying to prevent us from passing
failure to provide treatment and the role of foreign
governments and drug companies in this failure is all the more
distressing when there is overwhelming evidence that
Nevirapine works for MTCT and that the drugs can be effective
for many people. Even the offer for free or reduced cost medications had
strings attached or was in one way or another unacceptable to
the South African government.
The role of all players needs to be analyzed.
imports and compulsory licensing must be investigated and
considered as possible alternatives.
The role of the U.S. government in drug pricing should
also be closely examined.
The U.S. government has offered loans that are tied to
American drugs, which was generally seen by the group as an
example of support with strings attached - reducing
competitive pricing and autonomy of choice.
“All that this does is once again propagate the
interests of the drug companies. We shouldn't have to be tied into buying drugs from that
company, we should be able to look for the best solution for
our own country.”
to be found to put pressure on the World Trade Organization.
There must be a lobby that says that this is not just a trade
issue, health is not a trade issue, and certain concessions
and exceptions have to be made.
There must also be a campaign that links access to
treatment to debt relief.
Such a campaign would also be looking at the laws that
govern patents and the production and import of generic
medicines, as well as getting greater commitment from drug
companies and governments to address this issue as an
immediate urgent need. Underpinning
this campaign, there should be increased research on treatment
as well as how to develop and maintain the health and
education infrastructure needed to support access to treatment
on a broad base.
is a fundamental human right to have access to testing,
counseling and treatment as well as to enhanced social and
health services. Voluntary counseling and testing (VTC) services must be fully
resourced and offer ongoing support and services for people
with HIV/AIDS and their families.
The stigma and denial that blocks the success of VTC
must be recognized and it was suggested that effective visits
by prominent African-Americans could go a long way to
addressing these concerns.
regards to the right to treatment, the TRIPS (Trade-Related
Aspects of Intellectual Property Rights) agreement should be
re-negotiated and drugs given without strings attached as well
as at reduced costs so that people will be able to exercise
individual choices about treatment.
The North/South inequity should be recognized for what
it does to world development
TRIPS agreement is an agreement that has really robbed the
developing countries in such a way that the drugs are in the
north and the disease remains in the south and… the U.S.
government should take a lead in saying that it should be
Business and Industry
transfer is an important component of HIV/AIDS education and
takes many forms, and the effective use of such technologies
must be developed.
and marketing about HIV/AIDS and related issues must be
stepped up. An
effective way to do this is through the development of
extensive recreation facilities. It was believed that a dramatic donor infusion to create
recreation programs for young people and communities would
have a dramatic impact on behavior and the epidemic.
There is nothing for young people to do and few
community recreation centers.
Through sport, libraries and other programs, effective
HIV/AIDS education could be done and new sub-cultures of
community and social interaction established.
development of sport and recreation facilities was regarded as
a significant area in which governments and donors could be
people could promote them and offer training and it would be a
lasting sustainable program.
based interventions should move beyond just safe sex messages
and should look at productivity and education about the global
impact of AIDS and ways to address it.
The links between poverty, work and business need to be
developed and the debate that the recent controversies have
sparked should be channeled in creative ways.
are no strategies or polices for households affected by
HIV/AIDS and there are no policies for orphans and
child-headed households. There was general agreement that the role of the extended
family was misunderstood and that many families are already
too over-extended to deal with orphans.
governments and donors need to give urgent attention to the
housing of orphans through new and creative housing schemes
and village approaches. The
objective should be to ensure that the orphans are kept in
school, are clothed, fed and cared for, and are socialized
into the society, not marginalized and tempted by crime and
are a particularly vulnerable group and child-headed households should not be considered an option.
There must be well-funded research to look at new ways
to conceptualize the orphan response and to assess the
long-term effects of such large numbers of children in need.
is little room for experimentation, but a long-term viable
solution must be found so that the children orphaned and
affected by HIV/AIDS are not increasingly vulnerable to
their membership and their structures, labor unions could be
very important in the development of programs to support
children and affected households.
This would also affect their workplace programs.
ILO should be encouraged to become involved in workplace
programs for child support and early education and training
opportunities for young people.
is an extensive network of food hawkers in South Africa. They can be trained as nutritional advisors so that they can
give advice to poor communities and households about the most
effective ways of eating well on limited budgets.
This would have the effect of improving the quality of
their work as well as having a direct impact on the general
well being of communities and households.
This could also have an impact on the MTCT programs, as
the general nutritional status of the women would improve.
Food and Social Support
area where foreign donors could be involved is in the
development of food aid programs similar to those launched at
times of national crisis.
This food aid could be in direct supplies of food
parcels to destitute families.
It could also be in the form of food co-ops and food
stamps, which are administered through the Department of
effects of care – whether home-based or diverted toward
groups such as young girls or the elderly – need to be
assessed and social support systems generated should be part
of the food and support programs.
Foreign governments could set up education structures
to train an extensive network of community-based care-givers
as well as education structures to ensure that young people do
not miss their educational opportunities.
effects of HIV/AIDS on the environment must also be
recognized. Of particular concern is the collapse of agriculture and the
deterioration of farming land; erosion and deforestation; the
uncontrolled dumping of waste, particularly in regard to home-
based care where refuse services are inadequate; the failure
to give people a proper burial for economic reasons; and fear
Part 3: CONCLUSION
support of foreign donors, including the US Government, is
recognized as crucial to the efforts to contain the spread of
HIV and to mitigate the effects of AIDS.
Foreign donor support is also crucial to efforts to
develop new social, economic and political formations that can
transcend this epidemic and allow for growth and development
is believed that ongoing support for the prevention programs
is crucial but this support should be based on proven
effectiveness. We must throw away what does not work and
develop new, creative and innovative programs.
list provided below is a full summary of areas in need of
attention, but the group felt that it is crucial to prioritize
in order to create a feeling that the epidemic is manageable.
Social support - food, treatment, counseling and
Recreational facilities and community
support is also needed in the following crucial areas:
Impact of HIV/AIDS on households and ways to
hold households together
Orphans and children in distress - through new
research and new strategies for housing and care
Youth programs to create an environment where
youth feel there is a purpose to being free from infection
An increased role of religious groups in
challenging discrimination as well as offering care and
Social support for women, as well as challenges
to the male dominated society through a range of serious
economic empowerment programs and the full participation of
men and women
Access to treatment - both for MTCT prevention
and general access
Development of a treatment supportive
Voluntary testing and counseling and long term
Extensive community development through the
building of recreational facilities, libraries, community
centers and linking these to sports training and social and
Food support and social services provision
Formal education support through the provision
of teachers and additional education for young care-givers
Greater workplace understanding through the
involvement of international labor organizations
Focused funding in consultation with government
and NGOs to sustain, support and evaluate the National AIDS
Lobbying for the end of restrictive trade
agreements and crippling debts
Support for cutting-edge and new solutions
Increased data collection and surveillance
Study trips and training in reliable
institutions in the U.S. or other countries, especially
fostering a north/south understanding
Extended visits to South Africa by good role
models who can give classes in sport, music and act as
inspirational role models
list is clearly not exhaustive and needs to be read in
conjunction with the donor and research list.
It is believed that it is still possible to turn this
epidemic around through new and creative ways of looking at
the affects of AIDS in South Africa and creating the
opportunity for fresh interventions and the identification of
key priority areas.
is not endless time for debate and discussion and foreign
governments need to move fast and with extensive programs so
that the progress of the epidemic can be halted and the
interventions can lead to the creation of a new society.
This new society will live through and beyond AIDS,
with new families, new communities and new social, economic
and political visions for the future.
discussion forum thanked the Africa-America Institute for the
opportunity to meet like this and debate the complex question
of HIV/AIDS in South Africa in a relaxed environment and looks
forward to seeing the results of the consultative process.
AREAS FOR DONOR SUPPORT
STD interventions on a massive scale
Upgrading and development of clinics and health
The Men's' Forum and gender programs
A Marshall plan for social relief
Data and surveillance
Treatment - MTCT and HAART
Capacity building and training
Policy development - e.g., MTCT, Rape, etc
Management of the epidemic and programs
Stigma and ongoing denial, prejudice and
Globalization and economic development
Orphans - child-headed households - the under 5
years and young adults
Care and its effects on older people
COMPLEMENTARY RESEARCH ISSUES
Sexuality and multiple partners
Behavior change and behavior determinants
Service delivery and new programs
Sexuality - masculinity and gender relations
Traditional leaders and traditional healers
Vaccines and treatment
Framing the African Epidemic
Statistics and data collection
Role of government, NGOs and CBOs
Race, class and culture
Business and workplace changes and challenges
By: Dr. Mary
Director, Centre for the Study of AIDS