Halfway between Rio de Janeiro and Cape Town, his yacht buffeted by nine-metre-high swells, his sail shredded by high winds, Sithembele ‘Joeâ€ Cata, battling to keep his 20-metre yacht upright and his breakfast down, asked himself what a poor black South African kid, who can’t swim, was doing crossing 5Â 700km of the stormy southern Atlantic.
It is a question many public-health experts are asking about loveLife, the trip’s sponsor and the world’s largest HIV-prevention campaign. Just how could this voyage help curb South Africa’s Aids epidemic?
The same is being asked of many of loveLife’s other Aids-prevention programmes: a television show that flew seven young South Africans to destinations around the world; a journey to Antartica for another half-dozen youths; and an advertising campaign that has left many South Africans confused.
loveLife maintains that its controversial and unorthodox campaign is designed to make teens more positive and future-focused under the assumption that these qualities will lead them to act more responsibly and avoid exposure to HIV.
But after more than five years and R780-million — more than half of it from the Kaiser Family Foundation and other non-profit organisations in the United States — the HIV infection rate among young South African teens remains disturbingly high. About one in 10 teenagers is HIV-positive and about six million people are infected.
Nevertheless, loveLife predicts that in another five years it will achieve its original goal, which was to cut infection rates among South African teenagers in half by 2004.
The debate over loveLife illustrates one of the enduring challenges of the epidemic. Two and a half decades since the discovery of the virus that causes Aids, scientists have found a cocktail of drugs to keep many of those infected alive, but they have been unable, despite vast resources lavished on the problem, to motivate people to remain free of HIV by reducing their sexual partners, delaying the onset of sex or using a condom.
‘We’ve failed at Aids prevention,â€ said Edward C Green, a senior scientist at Harvard University’s Centre for Population and Development Studies and an authority on Aids. ‘It is something of an embarrassment.â€
Nations throughout Southern Africa and NGOs are no longer short of funds for prevention. They are, however, surprisingly short of models for spending it effectively.
In the absence of proven methods, money is being showered on programmes like loveLife — expensive experiments in social engineering.
This year the South African government increased its support for the programme and now provides a third of loveLife’s budget.
loveLife’s premise is that optimistic and informed youth will take precautions if the sales pitch is right. loveLife uses a slick marketing campaign and volunteers in government health clinics and schools to pitch its slogan — positive living. This is shorthand for a lifestyle in which condoms are cool, abstaining from sex is hip and hanging out in ‘chill roomsâ€ is the in-thing.
Anecdotal evidence suggests that loveLife has helped South Africans talk more openly about sex, and provided tens of thousands of schoolchildren with knowledge of HIV/Aids.
‘loveLife has been most visible in getting messages across to the youth, promoting positive and healthy lifestyles,â€ former deputy president Jacob Zuma said in a speech last year. He credited it with contributing to ‘a more open debate about the connection between HIV and sexual behaviourâ€.
Unfortunately, there are few signs so far that this new knowledge is prompting the youth to delay sex or reduce the number of sexual partners.
A study of more than 11 000 youths, aged 15 to 24, released last year found that those who participated in loveLife programmes were less likely to be HIV-positive. They were also more likely to use condoms and be tested for HIV.
However, the study did not make clear whether loveLife caused these differences or if youngsters who do not have HIV are more likely to participate in loveLife activities. More research is needed to understand the programme’s impact.
In the meantime, loveLife urges patience and optimism.
A visit to a few of the programme’s adolescent-friendly clinics with David Harrison, loveLife’s CEO, puts such optimism to the test.
Phasa Clinic in Lebowa, near Polokwane, one of loveLife’s nearly 200 adolescent-friendly clinics, couldn’t provide HIV-testing or examinations for other sexually transmitted diseases. The nurse on duty wasn’t trained to do either.
Outside, loveLife was building a sports court and one of its purple ‘chill roomsâ€, where teens can attend loveLife classes and activities.
‘Does it contribute to HIV prevention?â€ asked Harrison. ‘I don’t know. But how can you come into a community like this and do nothing?â€
Selepe Clinic, south of Warmbaths, another loveLife clinic not far away, has been without running water since its water pump broke in 1998. A year later, its generator quit. Next door, loveLife is building another ‘chill roomâ€.
Its nurses are trained to perform HIV tests and identify and treat sexually transmitted diseases, but most teenage girls visit the clinic for injectable contraception, protecting them from pregnancy — but not Aids. A minority also take the free condoms.
At loveLife’s youth centre in Orange Farm, south of Johannesburg, Sherriff Makhabelesa (21) was finishing a course about sex, Aids, staying healthy and resisting peer pressure. The class, taught by a loveLife volunteer, is a requirement for anyone who wants to use the centre’s computer room, health clinic and sports programmes.
‘Aids started here as a myth. Some people still say it doesn’t exist,â€ said Makhabelesa. ‘Parents think that they lose their dignity if they talk about sex with their children.â€
He pledged to take responsibility and learn his HIV status. Easier said than done. The youth centre offers judo, basketball and computer courses, but not HIV testing.
loveLife’s priorities — its sports fields, trips around the world for volunteers and computer rooms — seem out of step with South Africa’s needs, said Archbishop Buti Tlhagale, Catholic bishop of Johannesburg and a loveLife board member. ‘It would do no harm to concentrate on core business,â€ he added.
Harrison defends these unorthodox investments, saying the computers, trips and chill rooms ‘tap into [teens’] aspirationsâ€.
Cata, the sailor from Khayelitsha, agrees. ‘loveLife is about HIV and Aids, but it is also about motivating youngsters. The trip motivated me.â€
But being positive about the future, studies have found, is not enough. People also need to be afraid of the disease and understand how to avoid it, said Green. loveLife, however, avoids the standard ‘keep it zipped or risk deathâ€ messages.
In fact, some of loveLife’s promotional materials seem to encourage sexual experimentation.
A loveLife pamphlet for teens proclaims, ‘Yes, Yes, Yes, sex is on our minds and in the air. Sex is going to be part of the rest of our lives. Thank your body, thank your hormones — this can be such fun!â€
Another advises teens always to carry condoms because ‘you never know when you’ll get the chance for some lovingâ€. These messages have outraged many experts.
‘loveLife may be compounding the problem as it glamorises sex,â€ said Richard Delate, a South African based researcher. ‘When you see many loveLife [materials], you think sex. That’s it.â€
Further muddying the campaign’s message are loveLife’s stylish but often cryptic advertisements. Current billboards bear an ambiguous message: ‘Born Freeâ€ with tag lines like, ‘Take Back the Futureâ€.
A 2003 study commissioned by loveLife analysed one of its billboard campaigns and found that between 19% and 62% of students (depending on the advert) understood the csmpaign. Those most at risk of contracting Aids — poor, rural and black students — had the most difficulty grasping the message. In one case, a group of teens mistakenly interpreted an advert to mean, ‘You must pressurise, force the girl to have sex with you.â€
Such concerns about loveLife should be a part of a healthy debate about the best way to tackle the epidemic. But there are worrying signs that in its eagerness to prove its worth, loveLife and the Kaiser Family Foundation have stifled the already anaemic debate about how to respond to Aids.
loveLife has responded to critics like Delate and Warren Parker, director of the Centre for Aids Development, Research and Evaluation, with hints of legal action. In one letter, Harrison accused Parker of harassment and said: ‘We will carefully monitor your actions with respect to loveLife, and should you persist, we will reserve all rights in this regard.â€
In another case, Kaiser’s senior vice-president, Michael Sinclair, demanded that a paper critical of loveLife be removed from the South African Health Review, which was funded by the Kaiser Family Foundation.
‘All publications we fund have to be submitted to us for scrutiny,â€ said Sinclair. ‘We want to ensure they are presented in a balanced way.â€
Just as troubling, said Parker, is evidence that loveLife may be misrepresenting data to bolster its cause.
Harrison admits there have been problems. ‘We have made a couple of glaring factual errors — Some statistics were consistently misrepresented,â€ he said.
A press release last year entitled ‘Participation in loveLife programmes protective against HIVâ€ is a good example. This is a claim that even the chairperson of loveLife’s unpaid international panel of experts, California-based Thomas Coates, said cannot be supported by data.
Coates said: ‘We don’t know whether loveLife is working.â€
A loveLife brochure released last year raises more concerns. It reads: ‘Two-thirds [of teens] say they have changed their behaviour as a result of loveLife including delaying or abstaining from sex.â€ But, although the teens reported such changes, questions in the survey about their actual behaviour showed no difference between loveLife participants and others in these two factors.
‘What they claim is dishonest and it is disreputable,â€ said Rachel Jewkes, director of the Gender and Health Group at South Africa’s Medical Research Council.
loveLife’s other promotional materials are similarly rosy, claiming — for example — that the organisation’s helpline receives an average of 250 000 calls a month. According to loveLife’s internal records, about 40% of those callers never get through because either all the lines are engaged or it is closed for the night.
Such misleading presentation of data could mean that the world never really learns the true impact of loveLife. ‘Clearly, if HIV prevention among youth in South Africa is to be addressed in a committed way, it must be addressed coherently and assessed objectively,â€ said Parker, in a presentation to the 2003 South African Aids Conference. ‘We can ill afford a journey in the wrong direction.â€
Harrison points out that pulling the plug on the campaign would be premature, as no one has yet provided a better model for HIV prevention. He added: ‘What we’re doing is better than nothing.â€–