Brian Williams
CROSSFIRE
In the Mail & Guardian of March 10 to 16, Mxolisi ka-Mankazana presents a thoughtful, reasoned analysis of HIV/Aids in South African and what is to be done. The article raises a number of important questions, many of which can be answered by drawing on the experience of the Mothusimpilo- Carletonville Project.
By 1995 it was clear that conditions in South Africa were such that a major epidemic of HIV infection was inevitable. The purpose of the Mothusimpilo- Carletonville project was to develop a community-based programme to reduce the spread of HIV.
When approached by social psychology lecturer Catherine Campbell and myself, the British Department for International Development committed R7-million for a project to develop ways of managing HIV/Aids in the biggest gold mining complex in the world. (Subsequently USAid and the Gauteng Department of Health have also provided substantial funding.)
At the same time, and quite independently, social worker Solly Moema and nursing sister Yodwa Mzaidume were involved in setting up the Carletonville Aids Committee.
The Mothusimpilo-Carletonville Project is overseen by a committee which includes representatives of the state, the mining industry and unions, scientific organisations, the Council for Scientific and Industrial Research, where I am based, and, most importantly, community-based organisations in Carletonville through the Carletonville Aids Committee.
The project has an intervention arm, focussing on community-based peer education and condom distribution, syndromic management of sexually transmitted diseases and now periodic presumptive treatment for women at high risk. There is a strong, scientific evaluation arm which uses quantitative biomedical and social surveys as well as extensive qualitative methods, including in-depth interviews and focus group discussions.
Robust epidemiological arguments show, and the experience of Thailand, Uganda and Senegal confirm, that the rates of transmission of HIV infection can be successfully reduced and the epidemic brought under control. The challenge is to find out how to do this in the particular circumstances of South Africa.
As suggested by ka-Mankazana, we have been doing routine, anonymous HIV testing for three years and this has provided us with the information we need both to target our intervention efforts most and, in the future, to evaluate the extent to which they succeed in reducing transmission. Among other things, these data show that the incidence of infection is highest in young women, and the prevalence peaks at 25 years of age. Among men the prevalence of infection increases more slowly with age and peaks at the age of 32 years. The reasons for this difference are the subject of our research but what is clear is that ways must be found to protect young women between the ages of 15 and 20 from becoming infected, as a matter of great urgency.
Ka-Mankazana asks about bridging populations. Clearly, if no one travelled, the epidemic could not spread. One reason why the worst affected countries in the world include Namibia, Botswana, Zimbabwe, Zambia and now South Africa, is the combination of migrant labour and a good transport infrastructure. In this sense, migrant workers and the women with whom they engage form a bridging population, which links urban and rural communities across Southern Africa. However, the infection rates in the general population are now so high that the epidemic would continue even if migrancy ceased overnight.
Prevalence rates among women attending ante-natal clinics are believed to give a reasonable representation of the infection rates among all adult women, with the proviso that they probably overestimate infection rates in young women and underestimate infection rates in older women. It is also believed, and confirmed by our data, that infection rates in men are about 75% of the rates in women. Ka- Mankazana is right: we need more sentinel sites, such as Carletonville, where more detailed studies can be done than is possible in the ante-natal clinic surveys, if we are to properly assess the state of the epidemic and to evaluate our interventions.
From the start, the Mothusimpilo- Carletonville project was designed to involve people from the local community at all levels through religious, political, social and occupational community structures – almost all of which are represented on the Carletonville Aids Committee – but especially women at high risk, mine workers, and youth in and out of school. Without real community ownership, projects such as this are unlikely to succeed in the long run.
Ka-Mankazana asks if we know what to do. The answer is complex and involves dealing with issues of sexuality, gender violence and poverty. It involves empowering some of the most marginalised women in our society and educating the captains of our industries about their responsibility in helping to manage HIV/Aids. There are many gaps in our knowledge and the scientists, local and international, working in Carletonville are trying to fill them as best we can.
Ka-Mankazana asks about sexual behavioural patterns. We are carrying out detailed studies of adolescent sexuality in the hope that we can understand better what is it that leads people to engage in high- risk sex when every day the epidemic becomes more apparent. We are exploring the role of socio-economic factors in determining the patterns of infection.
The project is now distributing half-a- million condoms a month in Carletonville, most of the health care providers have been trained in the proper management of sexually transmitted diseases, a cadre of women at high risk have been trained to do community-based outreach and peer education, and the project is preparing to train mine workers and school pupils to do the same with their peers. Support is being provided to the local home-based care programme.
The project has taught us valuable lessons that should be widely applied. We are hoping to extend the work to a neighbouring mining area very soon and we believe that similar programmes across the country, and indeed the region, could dramatically alter the course of the epidemic.
The time scale needed for programmes such as this to succeed in reducing the spread of HIV remains to be seen. In communities as diverse and complex as that in Carletonville the task of bringing all the stakeholders on board with their widely varying interests, motivations and understandings of the problem of HIV/Aids has been challenging. It is really only now, more than two years after we started the work on the ground, that we have succeeded in mobilising key sectors of the community around HIV/Aids and even now some stakeholders are not yet fully on board.
We would advise communities interested in following our approach to set aside time and resources for organisational development and for the development of a health system capable of pulling together the diverse inputs and contributions that the various stakeholders can make.
This process of community and organisational development should take place prior to the expectation of any concrete results in terms of increased condom use and reduced levels of sexually transmitted diseases. We still have a lot to learn about the time it takes for community ownership of a problem to translate into concrete health outcomes.
Brian Williams is an epidemiologist who has also worked on projects dealing with occupational diseases of mineworkers
ENDS