By discounting the role that poverty and inequality play in HIV
By discounting the role that poverty and inequality play in HIV, Helen Zille may be ignoring some of the most important social determinants of health. (Oupa Nkosi)

More than 30 years into the epidemic, HIV continues to hold a mirror to society and exposes our prejudices and injustices.


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Aids is a mirror that reflects how we think about society. It displays whether we judge those different from us harshly, or embrace them in their diversity, and whether we view those with less education and more disease as our equals, or as lesser beings. HIV, with all its intricacies, reveals the state of societies around the world. It exposes dysfunction, from racial and gender prejudice to political inaction and homophobia. It also highlights the ever-widening gap between rich and poor.

Inequality, in all its forms, is what HIV — the cause of Aids — thrives on. HIV constantly reminds us of the complex relationship between power, powerlessness and sexuality.

When we follow the trail of the virus, where it’s moving and how rapidly, it takes us directly to poorer communities, where women are mostly powerless.

In South Africa, that community consists increasingly of black teenage girls and young women between the ages of 15 and 24. According to the Human Sciences Research Council, about  a quarter of all new HIV infections in the country happen in this age group, and most of them are black. Studies show they acquire HIV at a rate three times faster than their male peers.

In our country HIV is largely transmitted through unprotected heterosexual sex. In other words, the virus is mostly spread through sex without a condom between a man and a woman.

What then, Western Cape Premier Helen Zille recently asked in a tweet, is wrong with us South Africans?

Why don’t people act on this knowledge? All we need to do, she argues, is to translate “scientific knowledge” into “behaviour change”.

Many of Zille’s almost one million Twitter followers agree with her. This insinuates that population groups with high HIV infection rates, such as young black women, deserve it, because they’re sleeping around and doing so without using condoms.

Research shows HIV spreads much faster in sexual interactions in which men have the power to dictate to women how, when and where sex happens.

Such sex mostly happens in poorer communities, where women depend on their partners for money.

That’s not just the case in South Africa. Around the world, including in developed countries, HIV infection is concentrated in “communities of inequality”. In the United States, for instance, HIV is spreading much faster among African Americans and Hispanic Americans, the poorest groups in that country, than among white Americans, who are wealthier.

When South African-born Hollywood actress Charlize Theron opened last week’s International Aids Conference in Durban with a speech that implied that inequality and its cousins — racism, sexism, poverty and homophobia — fuel the spread of HIV, she was correct, and research about the social determinants of health confirms that.

Yet, ironically, Zille and her followers branded Theron ignorant. In a commentary, Bhekisisa criticised Zille for being irresponsible by underplaying the economic and social forces that shape the dynamics of HIV transmission. But we too were accused of not understanding the cause of Aids.

Zille and her supporters argue, if they and their middle-class friends are able to stick to one sexual partner and successfully negotiate condom use, then impoverished young women in the townships can too. And, Zille tweeted, people who disagree with her are suggesting that “blessers” can carry on infecting young women “because it is racist to suggest they stop”.

Of course people need to take responsibility for having unprotected sex.

But what happens if a woman isn’t able to negotiate for safe sex? Or if she doesn’t have employable skills and therefore feels forced to have relationships in which she exchanges sex for money and food?

study released at the Durban conference by the Centre for the Programme of Aids Research found that, as in some of the poorer KwaZulu-Natal communities,  “blessers” — men who have relationships with girls or women much younger and poorer than them — are indeed a powerful engine behind the rapid spread of HIV among young women. The study traced about 60% of all new HIV infections among trial participants to older men.

So why are Zille and her friends then wrong to imply that solving the spread of HIV is as simple as telling young women and “blessers” to use condoms, or to stop having sex with each other? Because the mirror through which they are looking is clouded by prejudice and ignorance.

One of the world’s most authoritative voices on the effect of inequality on the spread of the disease, the American anthropologist and doctor Paul Farmer, labels such views “narrowly construed”.

“A meaningful discussion of [infection] risk cannot be limited to medical issues,” he explains in his book Infections and Inequalities. “If we are to present meaningful responses to Aids, we must examine the differential economy of risk.”

Farmer points out: “Simply making condoms available is an insufficient response” because expecting a woman in an equal power relationship to negotiate for safer sex is different from expecting a woman who is financially dependent on a man, or several men, for survival, and who is also considerably younger than her sexual partner, to do so.

The “blesser” phenomenon is not a cultural invention; it’s a practice for which inequality, in the form of poverty, has created a demand.

If we want to fight the spread of HIV successfully, we can therefore not merely make medical interventions, such as condom use, the new HIV prevention pill, or even  medical male circumcision, available, and expect everyone to use them in the same way. That would be unscientific. Studies have shown that we also need to create environments in which people are more empowered to use those interventions.

In the case of HIV, one of the crucial factors to consider is access to education. It gives girls and women more skills that will make it easier to find employment and lift them out of poverty. That is likely to decrease the market for relationships with men in exchange for money, clothes or food. Research shows that women in equal power relationships are far more successful in negotiating for condom use or monogamy than those who are not.

A study published earlier this year in The Lancet revealed that one additional year of high school decreases a teenage girl’s risk of contracting HIV by a third. Because of structural injustices black women have had far less access to education than their white peers. In 2011, 15% of black women had no formal schooling, according to Statistics South Africa.

HIV initiatives, such as the United States government’s Dreams programme and the South African government’s recently launched National Campaign for Young Women and Girls, address HIV on a much broader level than merely in the medical sense.

High-profile political leaders who deny the economy of HIV risk and multifaceted solutions to the spread of HIV are irresponsible and, in effect, help to spread the virus. They stigmatise those with HIV because they encourage others to view people with HIV through a mirror of prejudice — a mirror that portrays them as simply badly behaved people who take no responsibility for their sexual behaviour.

We should strive to create an environment in which there is no market for “blessers”, a space in which inequality and prejudice are limited as much as possible, where it’s possible to give everyone education about sex and where we know they are empowered enough to apply it.

In such a space, the spread of HIV will dwindle rapidly.