Verdict out on South Africa's anti-HIV efforts
Infection rate still high despite program's unorthodox efforts

http://www.sfgate.com/cgi-bin/article.cgi?file=/c/a/2005/08/14/MNGUSE7Q4S1.DTL

Cape Town, South Africa -- LoveLife, South Africa's main AIDS prevention
campaign for young people, funded in large part by the Henry J. Kaiser
Family Foundation, maintains that its unorthodox approach, including
sponsoring sports teams, trips, youth centers and help lines, is designed to
make teens more positive and future-focused so they will take steps to avoid
exposure to HIV.

But after more than five years and $130 million for the program -- about
half of it from the Kaiser foundation, based in Menlo Park, with smaller
sums from the South African government, the Global Fund to Fight AIDS,
Tuberculosis and Malaria and the Bill and Melinda Gates Foundation -- the
HIV infection rate among young South Africans remains disturbingly high.

With an estimated 5.6 million people infected, South Africa has the grim
distinction of having more people with HIV than any other country, and more
than North and South America and Europe combined. About 10 percent of its
teenagers are HIV-positive, according to UNAIDS, the United Nations program.

The infection rate does not appear to be dropping significantly. In fact,
the latest results from tests at government health centers show that HIV
rates for pregnant women younger than 20 have remained stagnant at about 15
percent, with rates for young adults age 20 to 24 hovering around 30
percent.

Nevertheless, loveLife, founded in 1999, 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, the world's largest HIV prevention campaign,
illustrates one of the challenges of the epidemic. More than two decades
after the discovery of the virus, scientists have found a cocktail of drugs
to keep many AIDS patients alive, but they have had a harder time motivating
people to remain free of HIV by reducing their sexual partners, delaying sex
and using condoms.

"We've failed at AIDS prevention," said Dr. Edward C. Green, a senior
scientist at Harvard University's Center for Population and Development
Studies and an authority on AIDS. "It is something of an embarrassment."

Meanwhile, loveLife has been discussed by the World Health Organization and
the World Bank as a model for prevention campaigns, according to sources
there.

"LoveLife is certainly one of the programs that we're learning from," said
Dr. Bruce Dick, an HIV and youth specialist at WHO. "LoveLife feels that
they have the answer to the questions people are struggling with in this
field. "

The Kaiser Family Foundation, which has invested about $200 million in South
Africa's health programs and $70 million in loveLife, has committed to
funding the program through 2010, said Michael Sinclair, the foundation's
senior vice president.

LoveLife uses a slick marketing campaign and puts 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 youth centers and "chill rooms" is the in thing.

Anecdotal evidence suggests that loveLife has helped South Africans talk
more openly about sex, and tens of thousands of schoolchildren have gained
basic knowledge of HIV and AIDS through the program.

"LoveLife has been most visible in getting messages across to the youth,
promoting positive and healthy lifestyles," 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 behavior."

Yet several scientists and public health experts are asking whether the
group's programs really work.

There are few signs so far that this new knowledge is prompting South
African adolescents to delay sex or reduce the number of sexual partners --
the key to stopping the epidemic.

The average South African teenager starts having sex at about 17, about the
same age as teens in the United States. However, South African girls often
have sex with much older and more sexually experienced men, dramatically
increasing their risk of contracting HIV. In addition, any unprotected
sexual activity in South Africa, a country saturated with HIV, is like
Russian roulette. One in 4 adults and 1 in 10 teenagers are HIV-positive.

There have been some signs of progress. One study of more than 11,000 people
ages 15 to 24 released last year found that those who participated in a
number of loveLife programs were less likely to be HIV-positive -- 8 percent
compared with 12 percent of those who did not participate. They were also
more likely to report using condoms and being tested for HIV. The study did
not make clear, however, if loveLife caused these differences or if teens
who do not have HIV are more likely to participate in loveLife activities.

More research is needed to understand the program's impact, experts agree.
LoveLife's director, staff and benefactors urge patience and optimism.

A visit to a few of the program's 200 or so Adolescent-Friendly Clinics with
Dr. David Harrison, loveLife's chief executive officer, puts such optimism
to the test.

Selepe Clinic, in rural Lebowa, a poor mining belt dotted with mud huts and
skinny goats three hours north of Johannesburg, is one such clinic. It has
been without running water since its pump broke, and nurses have carried
jugs of water to work ever since. When its generator quit, nurses had to
deliver babies by candlelight.

Next door to the clinic, loveLife is building one of its trademark purple
"chill rooms," where teens can attend classes and activities. The nurses are
trained to perform HIV tests and identify and treat sexually transmitted
diseases, but few patients are interested, despite the work of loveLife
volunteers who visit schools and hold classes in the clinic. Instead, most
teenage girls visit the clinic at one time of the month, for one service.

"At month's end (when local miners get paid), the schoolgirls come for
contraception and then go to see the miners," said Monica Mpaketsane, the
clinic's nurse.

Paging through the clinic's dog-eared ledger of two dozen teenage girls who
visited at last month's end, Mpaketsane sighed and said she provided each
with injectable contraception, protecting them from pregnancy -- but not
AIDS -- for a few months. A minority, she said, also take the free condoms
she distributes.

"The girls will tell you that their 'boyfriends' don't like condoms," she
said.

At loveLife's youth center in Orange Farm just outside Johannesburg, the
purple youth center is surrounded by tumbledown homes on dusty plots.
Ephraim Motloheloa, 25, and Sherriff Makhabelesa, 21, were finishing the
last day of a weeklong course about sex, AIDS, staying healthy, planning for
the future and resisting peer pressure. The class, taught by a loveLife
volunteer, is mandatory for anyone who wants to use the youth center, with
its computer room, health clinic and sports programs.

"AIDS started here as a myth. Some people still say it doesn't exist, and
our parents won't discuss it," Makhabelesa said. "Parents think that they
lose their dignity if they talk about sex with their children."

Both young men pledged to take responsibility and learn their HIV status.

Easier said than done. The youth center offers judo, basketball and computer
courses, but not HIV testing.

Harrison, the loveLife CEO, defends the campaign's unorthodox investments as
necessary to "sparking a social movement driven by young people." The
computers, trips and chill rooms "tap into (teens') aspirations," he said.

But critics say that being positive about the future is not enough. People
need to be afraid of the disease and have knowledge of how to avoid it, said
Harvard's Green.

LoveLife avoids the standard "keep it zipped or risk death" messages.
Instead, it encourages young people to talk about sex in frank language.

A loveLife pamphlet for teenagers that covers everything from pimples to
condom usage proclaimed, "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!'' Another advises teens to always
carry condoms because "you never know when you'll get the chance for some
loving."

The approach has shocked some South Africans and AIDS experts.

"LoveLife may be compounding the problem as it glamorizes sex,'' said
Richard Delate, a South Africa-based researcher. "When you see many loveLife
(materials), you think sex. That's it."

Further muddying the campaign's message are loveLife's stylish but often
cryptic advertisements. Past billboards have featured the words "climax-
anticlimax" and "get attitude." The current campaign features the slogan
"Born Free" and taglines like "embrace life" and "take back the future."
None of the ads makes clear the link between sex and AIDS, nor do they
advocate any preventive action.

A 2003 study commissioned by loveLife analyzed one of its billboard
campaigns and found that between 19 percent and 62 percent of students
(depending on the ad) understood them. 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 teenagers misunderstood an ad to mean,
"You must pressurize, force the girl to have sex with you."

In addition, there are worrying signs that loveLife and the Kaiser
foundation have stifled the debate in South Africa about how to respond to

AIDS.
In one case, Kaiser's Sinclair demanded that a paper critical of loveLife be
removed from the South African Health Review, which at the time was also
funded by Kaiser.

"All publications we fund have to be submitted to us for scrutiny,''
Sinclair said. "We want to ensure they are presented in a balanced way."

Just as troubling is evidence that loveLife may be misrepresenting data
collected by the Reproductive Health Research Unit at the University of the
Witwatersrand in Johannesburg and the Medical Research Council of South
Africa to bolster its cause, said Warren Parker, director of the Center for
AIDS Development, Research and Evaluation in Johannesburg.

Harrison admitted there have been problems. "We have made a couple of
glaring factual errors. ... Some statistics were consistently
misrepresented, '' he said. "We didn't have a good research team. We had a
media team."

Dr. Rachel Jewkes, director of the Gender and Health Group at South Africa's
Medical Research Council and a frequent critic of loveLife, derides the
campaign's tactics. "What they claim is dishonest, and it is disreputable,
'' she said. "It is part of a pattern."

Last year, loveLife issued a press release entitled "Participation in
loveLife programmes protective against HIV." This is a claim even the
chairman of loveLife's board of experts says cannot be substantiated.

"It is premature to say that it is protective (against HIV)," said Dr.
Thomas Coates, an expert in HIV prevention at UCLA's medical school who
heads an unpaid panel of international experts assembled to advise loveLife
on its research. "We don't know whether loveLife is working.''