By Jeremy Laurance, Health Editor in Soweto
All interiors are dark in Africa. Small windows are curtained against the dazzling light. But nothing can dim the light in Nombuleloâs eyes. After years of playing the traditional, obedient South African wife, she has cast off submissiveness and found her own voice.
A woman who is infected through no fault of her own is still routinely abandoned, even if it is the husband who infected her in the first place.
"I am glad I told my partner I was HIV-positive because now I am free," she says. Her partner walked out, leaving Nombulelo to care for four of her own children plus five of her brotherâs and four of her sisterâs. Both of her siblings died of Aids. It is a costly kind of freedom, but now Nombulelo can speak her mind. The death sentence that is an HIV diagnosis has liberated her to act as witness against its cause. She is one of a growing band of women who are defying the stigma attached to the disease and speaking out against the main driver of the epidemic: men.
The world has put its faith in the arrival of cheap, anti-retroviral (ARV) drugs to save Africa from devastation. The World Health Organisation has just set out its "three by five" strategy - aimed at delivering the drugs to three million people by 2005 - in its annual World Health Report. A tour last week of three African countries - South Africa, Angola and Zambia - shows that the drugs are finally reaching the hospitals and clinics at the front line. But while drugs are a crucial part of the strategy to tackle Aids, they cannot solve the crisis. They may even fuel the epidemic if the numbers surviving with HIV grow. There is also the risk of drug resistance emerging if patients do not take them consistently - a major challenge in societies where chaos and insecurity are the norm.
Or if the drugs are shared out by uneducated patients, a common result of distributing long term prescriptions without medical supervision.
If Africa is to be saved it will be by women like Nombulelo. A vivid red and blue bandana ties her hair, the only splash of colour in the room at the Chris Hani Baragwanath hospital in Soweto, South Africa, where she works. Standing with one hip thrust forward, chin raised, she said: "I disclosed to my partner and he left us. It was his girlfriend who gave it to us - she is dead now. We women have to bring our partners for testing - but it is not easy."
Criminal prosecution of those who knowingly infect others might help.
She tells her story with dignity and composure. Only once, as she sets out the school fees she has to find for her monstrously swollen family do her eyes brim. "We have coped, but in the last year it has been hard," she says, a single tear spilling down her cheek. The burden of Aids falls disproportionately on women. In South Africa, one in four women are HIV positive by the age of 24, twice the infection rate in men. Teenage girls have sex with, and are infected by, older men - one symptom of the gender inequality that drives the Aids epidemic. Men become infected later. Overall, of the 25 million people living with HIV/Aids in sub-Saharan Africa, 58 per cent are women and 42 per cent men. For men, Aids is a distant threat. A disease that takes 10 years to kill hardly ranks against all other perils. But for women it shapes their lives. They care for the sick, worry about passing on the virus and worry about who will care for them when they are gone. In South Africa, more than half a million children have been orphaned by Aids and the number is projected to triple by 2010.
Behaviour change is the mantra that is uttered repeatedly in the era of Aids. But the ABC message - Abstain, Be faithful or use a Condom - is misdirected. It is men who need to change and women the only people able to make them do so. Men initiate sex, men control it and men pay for it with their greater wealth. (In Africa, once people become wealthy, they become more vulnerable to HIV.) For men, behaviour change is about denial. But for women, it means liberation. Empowering women through legal, educational and economic measures is the way to change men.
Sibu, 20, who lost both her parents to Aids and now works for Lovelife, the HIV/Aids prevention campaign for young people in South Africa supported by the US charity the Kaiser Family Foundation, said: "Girls are expected to be submissive, not independent. They want a girl who calls them up and pleads âCan you give me 50 bucks for clothes?â Men donât want a girl who is independent, has money, can buy her own clothes. They run - whoosh."
Boys, and men, are the hardest to engage in Aids prevention. In Kwa Zulu Natal, the fertile coastal strip where fields of sugar cane stretch to the horizon, the Gamalake clinic supported by Lovelife offers condoms and treatment for sexually transmitted infections to young people. But 80 per cent of its clients are girls and only 20 per cent boys. Sister Sedaki, who runs the clinic, says: "We need strategies for bringing in the boys. Boys are stupid stubborn." I put this point to Colonel Joao de Deus, head of Aids prevention for the Angolan Armed Forces. Did he accept that without men there would be no Aids epidemic? The colonel, a big man with a bull neck, paused."This is a sensitive social issue. We cannot change it overnight," he then said. Sitting next to him, Colonel Francisco Ernesto, head of public health, delivered a smart riposte. "Polygamy is common in Muslim countries with low rates of HIV, so that cannot be the problem."
Reluctance to acknowledge the crucial role that men play in the epidemic is unsurprising in a country where a manâs status is measured by the number of his female partners. A Portuguese doctor at the dinner later whispered to me: "If you are a general you have three or four women, each with an apartment and a car. It is natural. It is expected." Angolaâs capital Luanda, formerly a city of 600,000, has seen its population swell to four million. Its chaotic rubbish-strewn streets, rutted and pot-holed, are home to a human deluge wandering beside and among gridlocked traffic. Yet in this former Portuguese colony, statuesque young women in improbably elegant clothes sashay down the dusty streets. Faustina, 23, a pretty translator, said: "Men with money - they pay the sex workers and the sex workers depend on the men. That is the problem." The best hope of changing attitudes is to encourage people to have HIV testing. Many have preferred not to know their HIV status because nothing could be done to help them but he arrival of ARV drugs has given testing a new purpose.
Mandatory testing of all adults might help.
All over southern Africa you hear the same story: where the drugs are available, people are more ready to be tested. Rolling out the drugs is crucial to delivering the prevention message. But there are problems. At Cajueiros hospital in Luanda, a young doctor who helps run the HIV clinic shows us into a small, stuffy room where the equipment for carrying out CD4 cell counts is housed. The air conditioning is broken and the reagents used in the process congeal in the heat. So the equipment is useless until the air conditioning can be fixed. In Zambia, where 23 per cent of the urban population is HIV positive, the main teaching hospital in Lusaka has lost a third of its nursing staff. Many left for better-paid jobs in Botswana, South Africa ... and the UK. There are also problems of compliance with drugs that may have unpleasant side effects, or no effect at all, and must be taken for life.
Witbank, 70km north of Johannesburg, where slag heaps loom over the squatters shacks, Anglo Coal has instituted an Aids treatment programme for its employees. By the end of March, 1,534 miners had started on ARV drugs. But a fifth dropped out and tests showed a fifth of those who said they took the drugs were not taking them as prescribed. Doctors have warned that if the ARVs are not taken as prescribed, there is a real risk of resistant strains of HIV developing which could worsen the epidemic. If drugs cannot solve the problem, women may. Across the continent, women are driving the campaign against Aids. But their low status and economic powerlessness makes them most vulnerable to it. A more concerted drive is needed to help Africaâs women. If the help were focused on women, it would be more likely to be taken up and, through them, have the greatest chance of impacting on men. Women have the incentive to change that men lack.
Gloria Kingu, a director of the Zambian Network of Persons Living with HIV/Aids, said: "The woman is the backbone of the African household. In marriage, a man becomes a child to a woman and she has to carry him to the end." The United States will propose next week a rapid review process to ensure it provides safe, effective Aids drugs to developing countries in the shortest time possible, under President George Bushâs $15bn Aids relief plan.
Some estimates range between 25% to 50% infection rates in certain areas. Africaâs death knell is sounding and its economically privileged chauvanistic men are vigorously tugging on the bell rope.
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