Democratic Alliance leader Helen Zille has a new approach to fighting AIDS. Impatient with the pace of government and NGO efforts, she now advocates a program of forced testing and criminal prosecution for those who knowingly transmit the virus.  

As AIDS experts have emphasized for decades, this won't work, and will almost certainly make things worse. In her article, Ms Zille favorably cites my book The Invisible Cure: Why we are Losing the Fight Against AIDS in Africa (Picador 2008) as evidence for her position. But the programs I call for in that book, and now, are precisely the opposite of Zille's.

In the book, I cite the examples of countries such as Uganda, Rwanda and the US where HIV rates had fallen, and Botswana and South Africa where (at the time of publication, at least) they had not. The policies in the successful countries involved not coercion, but openness and compassion. I don't even mention mandatory testing and disclosure, or criminalization of transmission. These are human rights abuses and must be totally off the menu.

Invisible Cure does argue that concurrent or overlapping partnerships are a major driver of the epidemic in Southern Africa. But it also presents evidence that the people of this region are neither especially "promiscuous" nor irresponsible in their sexual behavior. In fact, well-conducted surveys show that over a lifetime, Americans have more partners over a lifetime than people in Africa do. So why are HIV rates so much higher in Eastern and Southern Africa than in America?

Probably because people in East and Southern Africa are more likely to have a small number-perhaps two or three, ongoing partnerships at a time, which may overlap for months or years. Americans, on the other hand, tend to be "serially monogamous", running through many more partners one after another. Even though the Africans end up with fewer partners in the long run, they are at greater risk because the networks of concurrent partnerships serve as a kind of "superhighway" for HIV. By switching from partner to partner, Americans largely avoid becoming trapped in such networks.

As Ms/ Zille indicates, Invisible Cure also argues that behavioral change, particularly partner reduction is crucial to bringing HIV rates down. But "partner reduction" is very difference from abstinence, or perfect monogamy and it cannot be coerced. Rather, it's a negotiated adjustment that must make sense within a particular culture. The greatest obstacle to making such adjustments are shame and denial, which inhibit open discussion of sexuality, relationships and risk.

Such discussions, carried out in an atmosphere of compassion, urgency and pragmatism, have been crucial to the control of HIV in every community where it has occurred. They are "The Invisible Cure".  The hypothesis of my book, based on research by epidemiologist Rand Stoneburner and has colleague Daniel Low-Beer is that in South Africa, where the epidemic and its victims have long been especially stigmatized, such personal, frank discussions have long been suppressed, with catastrophic results.

Here's a passage from the book:

When I was in Uganda during the early 1990s, the HIV rate was already falling, and I vividly recall how the reality of AIDS was alive in people's minds. Kampala taxi drivers talked as passionately about AIDS as taxi drivers elsewhere discuss politics or football. And they talked about it in a way that would seem foreign to many in South Africa because it was so personal: "my sister," "my father," "my neighbor," "my friend."...

Stoneburner and Low-Beer maintain that these painful personal conversations did more than anything else to persuade Ugandans to come to terms with the reality of AIDS, care for the afflicted, and change their behavior. This in turn led to declines in HIV transmission. The researchers found that people in other sub-Saharan African countries were far less likely to have such discussions. In South Africa, people told Stoneburner and Low-Beer that they had heard about the epidemic from posters, radio, newspapers, and clinics, as well as from occasional mass rallies, schools, and village meetings; but they seldom spoke about it with the people they knew. They were also far less likely to admit knowing someone with AIDS or to be willing to care for an AIDS patient. It may be no coincidence that the HIV rate in South Africa rose higher than it ever did in Uganda, and has taken far longer to fall.

Why did South Africans respond this way? And why were Ugandans, American gay men and the people of many other societies so much more open about AIDS early on? I don't know, but it may have to do with the legacy of racial oppression, and the long shadow of the poisonous ideas that justified it: that blacks were inferior, oversexed beings. Some HIV prevention campaigns helped reinforce this idea, by focusing on so-called "high risk groups-promiscuous youth, prostitutes and truck drivers, and ignoring the prevailing norm of concurrency which has put so many ordinary, "non-promiscuous" South Africans at risk.

It's heartening that groups like Soul City are now working to inform people about the risks networks of concurrent partnerships pose, even to those with only one or a small number of sexual partners. But it is deeply worrying that Ms. Zille seems to be reviving stereotypes of the promiscuous African, and advocating draconian policies that can only squelch the kinds of compassionate, non-judgmental conversations that are needed to spread awareness and encourage voluntary changes in behavior.

Still, I'm optimistic for South Africa, in part because the response to Zille has been so vociferous. Maybe this just reflects the contested nature of historical progress, and South Africa's ongoing struggle out of the darkness of its past. If it gets people talking about AIDS and other things-that can only be hopeful.

Helen Epstein

New York

November 23, 2011

This letter first appeared in the Cape Times

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