Reviewed by Marc Epprecht (Department of Global Development Studies, Queen's University, Kingston)
Published on H-SAfrica (May, 2007)
HIV/AIDS in South Africa has thirty-six chapters running the gamut from virology to epidemiology to social science and more. It contains a vast amount of specialized information. In most cases, this comes with an abstract as an introduction, and a forward-looking conclusion (such as asking what the implications of this knowledge are for future interventions). In addition, manageable lists of select references offer a foot in the door to often-distinct, compartmentalized fields of knowledge.
The chapters follow the same basic pattern. Specialists provide an overview of the fundamentals of their field (for example, how the virus works, how and why testing is done, how HIV interacts with tuberculosis and other diseases, how anti-viral drugs work), lessons learned and technological advances made in the struggle so far (for example, new drugs, new barrier methods, the development of strategies to protect the blood supply), and state-of-the-art or promising new directions that research is poised to take (such as, a vaccine for Herpes simplex virus II, volunteer counseling and testing, and male circumcision).
Several contributions touch on issues decidedly under-represented in this type of text. Jerome Singh, for example, has a strong chapter on the impact of the disease on medical research ethics, including case studies of the debates surrounding the use of placebos in trials for new drugs, or case studies of researchers and clinicians confronting conflicting "dual loyalties." Ted Leggett discusses intravenous drug use (mostly heroin), an issue often completely overlooked in Africa, even though it is clearly on the cusp of becoming a major public health disaster. Several chapters discuss heterosexual anal sex, another commonly overlooked or negated issue in Africa. The numbers involved here are deeply disturbing, making the usual silences even more problematic. For instance, Quarraisha Abdool Karim reports that the risk for women of contracting the virus through receptive anal intercourse is four times higher than receptive vaginal intercourse, and that 10-30 percent of heterosexual couples report engaging in anal sex (p. 257). In a survey of sex workers and clients along the Durban-Johannesburg highway, Gita Ramjee found that nearly half of the truck drivers reported practicing anal sex (p. 293). Infection rates among those tested ranged as high as 95 percent.
At times, the technical detail and the surges of statistics threaten to overwhelm. A welcome respite in that respect is the chapter by Lilian Mboyi. Here, Mboyi gives a personal and remarkably frank memoir of how she became infected and what it is like to live with the stigma of HIV as a middle-class black woman in South Africa today.
The editors are confident that the pandemic can be contained now that the government of South Africa has adopted policies in line with the best scientific research. Certainly, the rates of infection have slowed or decreased in the last few years and the prevalence of HIV appears overall to have stabilized. Individual contributors do not always share confidence that this represents success. For example, the chapter on HIV-1 genetic diversity suggests, in an understated way, that even the low level of control in place at present will be difficult to maintain in the face of "inevitable future diversification of the virus" (p. 117). The chapter that discusses the origin (at least three distinct cases of zoonosis from simian immunodeficiency viruses) alerts us to the strong possibility that new and potentially more virulent strains could emerge. Alan Whiteside, again in quite understated if not euphemistic terms, suggests that conventional economic models that value growth in economistic terms might actually interpret the maturity of the disease in a positive way.
The book announces its politics with judicious criticism of the racist regime that was in place when HIV/AIDS first appeared, and unambiguous denunciations of the "confusion and obtuseness" and "litany of errors" in nearly a decade of post-apartheid government (p. 35). Mark Heywood of the AIDS Law Project and Treatment Action Campaign gives a blistering attack on Thabo Mbeki and the false dichotomy of poverty versus treatment arguments, in particular. Strangely, the editors conclude by letting Mbeki and his political minions, somewhat, off the hook of culpability for the years of delay and obstruction: "There have been too many other high priorities and distractions in the country" (p. 572). Others would point to, and can provide considerable evidence for, negligence, incompetence, hypocrisy, and cynicism at the highest levels, but, admittedly, that would detract from the desire to combat pessimism.
The book claims to be written at an accessible level. In fact, much of it assumes a relatively sophisticated audience, such as people who teach courses on HIV/AIDS and the social history or sociology of contemporary South Africa. I have been doing that for years, yet there were still times when I could not clearly understand the text. Additionally, I often felt unnecessarily wearied by constantly having to interpret jargon-encrusted sentences. For example, in a discussion of the relationship between malaria and HIV, why write, "Chemoprophylaxis must be accompanied by vector control" (p. 461)? One could surely communicate the same idea by saying "anti-malarial drugs need to be combined with mosquito nets."
Frustration also sets in as the topics not discussed accumulate. Because HIV/AIDS in South Africa describes itself as a "definitive text," it is appropriate to note several of these glaring gaps and gaffes. For example, almost everyone today will agree that HIV/AIDS needs assessing in regional rather than national terms. Yet, this book is almost stunningly silent on South Africa's neighbors. There are no references to Lesotho, Swaziland, or Mozambique, not even in the chapter on male labor migration. Malawi and Zimbabwe, mentioned only once and thrice respectively, do a bit better, while Botswana gets almost two pages. This strikes me as self-defeating South African parochialism, particularly since there have been noteworthy successes and failures in tackling the disease in these countries.
Another worry is the relentless heterosexism of the analysis. This book continues and hence tacitly condones the silence/ignorance, despite the fact that South Africa has a vocal and vibrant gay rights lobby; that the World Health Organization and the South African Constitutional Court, among many others, have recognized the pernicious impact of homophobia on society and sexual health in the majority (straight) population; and that numerous empirical studies from around Africa now suggest that men who have sex with men have been understated in mainstream HIV/AIDS discourse. The index contains precisely two references to "homosexuality," both of which lead the reader to passing mentions of the original outbreak among gay white males. To be sure, there are other passing mentions of men who have sex with men in some of the chapters that do not make it into the index, as well as a single acknowledgement that homophobia is a contributing factor to more generalized stigma surrounding the disease (p. 149). But there is nothing to counter the dominant narrative in Africa that says homosexualities are irrelevant outside small white populations.
A chapter on prisons (which do not get a single nod in the index) would have been helpful in this regard, especially considering that South Africa has one of the highest rates of incarceration in the world. With around 160,000 people in the well-known high-risk environment of prison, South Africa incarcerates more individuals than the population giant Nigeria by a factor of four-to-one, and at two to three times the rate of regimes notorious for human rights abuses, such as Zimbabwe, Egypt, and Burundi.
A final absence of note is the paucity of discussion on traditional healers and beliefs. Writers have often proposed that traditional healers could be co-opted and trained to fill in the gaps left by the modern, professional health services. It has also been proposed, and in some cases backed by careful ethnographic studies, that witchcraft beliefs comprise a critical piece of the puzzle that one overlooks at peril. HIV/AIDS in South Africa overlooks them, while also failing to acknowledge critical weaknesses in the practice of Western biomedical science in Africa. The history of those weaknesses--including arrogance, colonialism, and ethical abuses--is highly pertinent to understanding why witchcraft and other conspiracy beliefs exercise such a formidable hold on popular consciousness.
If HIV/AIDS in South Africa is not quite as definitive as it claims, it is, nonetheless, a valuable contribution to the struggle to fight the disease in the region. Non-scientists can only benefit from clarifying and substantiating their knowledge of the underlying sciences. Health care professionals will likely also appreciate a reliable single-source resource for understanding the complex interplay of science, culture, economics, and politics that makes the disease so apparently intractable in South Africa.
. Cary Alan Johnson and Leigh Tomppert, Off the Map: How HIV/AIDS Programming Is Failing Same-Sex Practicing People in Africa (New York: International Gay and Lesbian Human Rights Commission, 2007); and Rachel Jewkes et al, "Factors Associated with HIV Serpositivity in Young, Rural South African Men," International Journal of Epidemiology 35 (2006): 1455-1460.
. Roy Walmsley, World Prison Population List, 7th ed. (London: International Centre for Prison Studies, 2007); and Sasha Gear and Kindiza Ngubeni, "Daai Ding": Sex, Sexual Violence, and Coercion in Men's Prisons (Braamfontein: Centre for the Study of Violence and Reconciliation, 2002).
. See Adam Ashforth, "An Epidemic of Witchcraft? The Implications of AIDS for the Post-Apartheid State," African Studies 61, no. 1 (2002): 121-143; C. Bawa Yamba, "Cosmologies in Turmoil: Witchfinding and AIDS in Chiawa, Zambia," Africa 67, no. 2 (1997): 200-223; and Alexander Rodlach, Witches, Westerners, and HIV: AIDS and Cultures of Blame in Africa (Walnut Creek, CA: Left Coast Press, 2006).
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Marc Epprecht. Review of Karim, S. S. Abdool; Karim, Q. Abdool, HIV/AIDS in South Africa.
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