In commemoration of World AIDS Day, December 1, Neon Tommy is featuring original reporting on the fight against HIV/AIDS in South Africa, a country with one of the highest HIV rates in the world. Be sure to check out our related infographic here.

South Africa’s Orange Farm township is a massive informal settlement where more than half a million people live mostly in ramshackle dwellings and use pit latrines. It’s also where Lerato Mahoyi got a new lease on life.

Mahoyi was a teenager living in Orange Farm, which is outside of Johannesburg, when she heard about an HIV-prevention group called loveLife. Growing up, Mahoyi had heard about the HIV epidemic ravaging impoverished townships like hers, but as the daughter of a domestic worker and an abusive father, she had even bigger problems to worry about - like her lack of opportunities or money for college.

One day in 2004 a friend convinced Mahoyi to come with her to one of the local loveLife youth centers, a squat, brightly-painted building where mentors work with young people in arts, academics and life skills. After one visit, Mahoyi was hooked.

A street in the Khayelitsha township in South Africa. Photo by Olga Khazan.

LoveLife’s tactic is peer-to-peer education, one of the most powerful strategies being used by organizations working to curb the spread of HIV in the townships of South Africa. The tactic involves getting people to tell their friends about the dangers of HIV in rural centers, churches or clinics, often with a dose of life-skills training on the side.  

“The positive energy that was running in the Y center made me so excited,” Mahoyi said. “There were people who believed in me, who believed I could be great.”

The so-called groundBreakers, or mentors, at loveLife each have five “friends” like Mahoyi, whom they lead in discussions about safe sex, goal-setting and how to forge a good future. Mahoyi is proof of the program’s success.

After she finished her training at the youth center, Mahoyi became a groundBreaker herself, and she later worked at a call center and as a loveLife intern in Cape Town. Instead of ending up jobless in the townships, she now works as a training assistant for the same organization that helped her get out.

The organization’s representatives say the infection rate among the young people loveLife has reached (85 percent of all South African youth) has declined by 50 percent since the program was launched in 1999. What’s more, the World Health Organization recognizes the program as the only one in the world that has a proven link to lower HIV rates.

A new focus on prevention

Since the HIV epidemic escalated in the ‘90s, South Africa’s national government has intensified knowledge campaigns about condoms and testing. However, HIV rates in South Africa’s least-urbanized provinces, like KwaZulu-Natal, still reach as high as 38 percent.

A recent report by the Human Science Resources Council showed no significant decline in the HIV rate for South Africans aged 15 to 49 between 2005 to 2008, as compared to the three previous years. In fact, condom use peaks at age 16, and as soon as South Africans leave high school, HIV rates spike. A main part of the problem, according to loveLife coordinator Botha Swarts, is the township lifestyle, where poverty and unemployment spawn risky behavior.

“Young girls would be willing to take a sugar daddy who will assist her with food or clothing - but that comes as a non-negotiable relationship,” Swarts said.

To reach their goal of cutting new infections in half by 2011, South Africa intensified its focus on preventing HIV infections through peer education.

“They’ve really upped their ante,” Swarts said. “We have a government that realizes the importance of prevention strategies. Prior to that they focused on [antiretroviral drugs] and knowledge.”

That’s where loveLife and other prevention programs come in. The goal is to give township residents the tools they need to overcome their surroundings.

“If we can empower that young girl to know what her options are and how to connect with people out there,” he said, “we are more likely to assist her in getting out of that high-risk zone.”

For their strategies to work, however, interventionist groups have to change behaviors and dispel myths about HIV. To do it, they send out peers to teach each other how to use female condoms, where to get tested, what it means to be HIV positive and how to avoid it.

Volunteering for treatment awareness in Khayelitsha

Khayelitsha is a sprawling township outside of Cape Town, where more than 400,000 people live in largey shack-like houses and children kick around soccer balls in dirt roads. The HIV rate is a scorchingly high 60 percent, and unemployment and alcoholism are also rampant.

There, women like Xoliswa Mntuyedwa work as volunteers with Treatment Action Campaign, a global AIDS-prevention nonprofit that has a Khayelitsha branch. She’s one of 10 local residents that the organization enlists to educate others on the importance of using condoms, knowing their status and getting on ARVs as soon as possible.

“When I joined Treatment Action Campaign, it gave me the chance to see other women who are very bold and open in talking about their status,” she said. “It gave me the strength and courage to say to myself, “If they can do it, why can't I do it?’”

Women like Mntuyedwa spend their days in treatment centers around Khayeltisha, speaking on various issues as residents wait in the hours-long queues to see a doctor. Sometimes the topic of the day is gender-based violence, while other times it’s how to prevent transmission of HIV from a mother to a child.

And sometimes, it’s just the honest truth about what HIV is – and isn’t. According to one volunteer, much of their work involves clearing up misconceptions about a disease that many in their township regard with fear and confusion.

“People wouldn't even want to sit next to you, to share a spoon with you,” said Bulelwa Lindiso, another volunteer. “People didn't even want to touch somebody who is HIV positive.”

Together, they work to uncover what has become a common condition from a shroud of mystery. Some of the volunteers are HIV positive, in which case they can provide insight into how to stay healthy while living with the disease.

“My main mission is to try and reduce infection rates,” said Nandipha Makhele, another volunteer. “I go to schools and I tell people my story - that I’m HIV positive, but that HIV will not kill me.”

Re-defining “macho”

But as they attempt to fight ignorance and unsafe sex practices, women like Makhele also face a common, yet particularly stubborn obstacle: the human male. TAC coordinator Mary-Jane Matsolo concedes that their style of peer education works faster on women than on men.

“Men have got issues,” Matsolo said. “It's a continuous structure to break through those walls.”

Most days, Mntuyedwa meets with married women just like her. Some of them, having found out they’re HIV positive, ask her what to do about their angry husbands who think it’s the wife’s fault there’s an infection in the family.

“The husband would like to blame the mother that she got this virus. The husband will not understand how the woman got the virus,” Mntuyedwa said. “As a married woman, my role is to strengthen and to give women who are in marriages courage.”

Dr. David Coetzee, a University of Cape Town professor, works in the Nolungile treatment clinic near Khayelitsha.

“Jonathan Mann once said that men are the biggest risk to public health in the world today,” Coetzee said, referring to a reknowned AIDS expert. “Perhaps he was right.”

Condoms work, Coetzee said. The problem is getting people to use them.

“It’s macho not to use a condom,” he said.

So is sleeping with more than one person at a time, apparently. More men than women have multiple sex partners, according to the 2010 South African HIV progress report released by the country’s health department in March.

The report also found that roughly equal numbers of men and women know about the causes and prevention of HIV, and men actually get tested in greater numbers than women do (52 percent to women’s 38.)

Despite this, African women are still infected at far greater rates – nearly 33 percent, compared with 24 percent of African males. The problem, according to Coetzee, could be women’s ability to negotiate sex, especially in poor environments.

“Many formal sex workers use condoms, but most of our problem with HIV in South Africa is sex in exchange for favors,” Coetzee said. “Women in poverty have sex to survive.”

In such situations, women may not be able to demand their partner use a condom. A recently developed antimicrobal vaginal gel, as well as a preventative anti retroviral pill, would give its users added HIV protection without the use of condoms.

When the gel debuted at the Vienna AIDS conference in July, it was lauded as a measure that could prevent up to 1.3 million infections worldwide in the next 20 years. But the excitement was tempered by the fact that it has yet to go through full clinic trials, and by the fact that it only cuts the chance of transmission in half.

“I think it’s a great opportunity to add contraception,” Swarts said, “but I’m scared it will create a hope that it will be 100 percent effective. Whether you’re using the gel or not, you should always use a condom.”

That’s why Swarts and others see strength in numbers, by creating networks of people – both HIV negative and positive, men and women – to spread knowledge about the disease in townships.

And the progress of peer-to-peer education is advancing, slowly but surely, even across gender divides. One of the Khayelitsha volunteers said there’s now a small but growing group of male advocates against gender-based violence and unprotected sex in Khayeltisha.

“It all starts with the women's sector – we are the ones who have to take the first step,” Mntuyedwa said. “The men tend to get strength from you. They get on the wagon as well.”

To reach Olga Khazan, click here. Follow her on Twitter here.

Reach Kevin Grant here. Follow him here on Twitter. 

Sign up for Neon Tommy's weekly e-mail newsletter.