JOHANNESBURG, South Africa — In Orange Farm, a sprawling, unincorporated shack town of more than 1 million inhabitants 30 miles outside of Johannesburg, Valencia Mofokeng sings to a group of toddlers in her care, coaxing them into an energetic dance. Then she turns and glances over to one corner, where her own 10-month-old daughter Palesa is gurgling on a pink blanket.
“She tested negative at 6 weeks,” Mofokeng says. “Now I have to wait until she is 18 months to do the next tests. But she seems fine.”
Mofokeng herself isn’t so lucky. After her husband died of AIDS, she learned that she had become one of the 5.5 million South Africans infected with the HIV virus. Mofokeng reacted to her predicament by doing what she could to help local children affected by the epidemic. She has adopted an HIV-positive nephew, and she stretches her meager salary to provide for 18 other children who were orphaned after their parents died from the disease.
At the day care center where Mofokeng works, all of the 30 children for whom she cares each day have seen their lives changed by HIV/AIDS in one way or another. Sickness and death have impoverished their families, so most come to school hungry. “I buy them maize meal and cooking oil, but you can’t live on maize meal alone,” she says. There is no food at home.” In Orange Farm, she says, young girls sometimes have no alternative but engage in transactional sex with older men so they can buy food. Others fall victim to sexual assaults by gangs, a rampant problem in Orange Farm.
Mofokeng tells an ICIJ reporter she knows who U.S. President George W. Bush is, and she’s vaguely aware that there is a new U.S. program to fight HIV/AIDS. But while the President’s Emergency Plan for AIDS Relief, or PEPFAR, is funding at least two HIV/AIDS treatment programs in the Orange Farm area, the need is so great that there seems to be little impact on the stark facts of life and death in Mofokeng’s neighborhood. “We are losing a lot of people each and every day,” she says, resignedly. “They need help, but we can’t access any grant money.”
That sort of frustration is echoed in both rural and urban communities across South Africa, where an estimated 500,000 people become infected by the HIV virus each year, and where AIDS claimed 320,000 lives in 2005. It is a nation in desperate need of the sort of help that PEPFAR, a five-year, $15 billion U.S. initiative to fight AIDS abroad, aims to provide. Indeed, the program is spending more in South Africa than anywhere else — $89.3 million in 2004, $148.2 million in 2005, and this year $221.5 million. But while PEPFAR clearly has done much good in South Africa, particularly in terms of funding antiretroviral drugs and other health care for HIV-positive people, it also has sparked a fierce controversy. Prominent South African HIV/AIDS activists have accused the Bush administration of using its financial clout to push sexual abstinence and faithfulness and to de-emphasize condom use — a moral choice that they say South Africa cannot afford to make, given that more than one in 10 people are infected. And there are complaints that PEPFAR money tends to flow to faith-based organizations that mix prevention efforts with evangelism — and that may not have much expertise with HIV and AIDS — while providing too little to other South Africans who are in dire need.
Resentment over control of funds
In a July 2006 speech in the South African administrative capital of Tshwane (formerly Pretoria), U.S. Chargéd’Affaires Don Teitelbaum painted a more positive picture of PEPFAR’s impact across South Africa. In addition to working with the South African government, he explained, PEPFAR has relationships with more than 300 nongovernmental organizations, 80 percent of them South African. He also said that through programs supported by PEPFAR, 75,000 South Africans are receiving antiretroviral drug treatment — which has largely transformed HIV/AIDS from a fatal condition to a manageable illness — and an additional 200,000 people with AIDS are receiving medical treatment to relieve their suffering. By 2008, according to Teitelbaum, PEPFAR aims to provide antiretroviral drug treatments to 500,000 people and hopes to significantly reduce the number of new infections through prevention programs.
“These goals and accomplishments are something about which President [Thabo] Mbeki and President Bush can be justifiably proud,” Teitelbaum said. “But they will only be achieved, and remain sustainable, if all the partners continue to work cooperatively.”
That may be a big “if.” At a meeting in Durban in June, the South African health minister, Dr. Manto Tshabalala-Msimang, complained that instead of the U.S. providing funding directly to nongovernmental organizations, it should give the South African government more control over the money. “Direct access by principal partners to PEPFAR funding poses a serious coordination and harmonization challenge,” she said. Tshabalala-Msimang also complained about the “conditionalities” attached to PEPFAR and external funding and argued that it would be better to give South Africa the funds without such strings attached.
(Tshabalala-Msimang, it should be noted, is herself a controversial figure, due to her advocacy of unorthodox, nonmedical treatments for HIV/AIDS. She has suggested, for example, that HIV-positive South Africans try a folk medicine regimen of garlic, beet root and olive oil instead of antiretroviral drugs. “These delay the development of HIV to AIDS-defining conditions, and that’s the truth,” she was widely quoted as insisting at a meeting in July. She also has come under fire for not taking action against a health-food entrepreneur who encourages HIV/AIDS patients to give up their drug regimens and instead try to control their disease with vitamin supplements.)
The Washington Post reported in October that the South African government has backed away from Tshabalala-Msimang’s assertions and that she has been supplanted by Deputy President Phumzile Mlambo-Ngcuka as the leader of the nation’s HIV/AIDS efforts.
Fatima Hassan, former deputy head of the AIDS Law Project, said that PEPFAR isn’t always as cooperative with South African officials as it could be. “Provincial health departments complain in private that PEPFAR does its monitoring and evaluation without coordinating with government or other programs,” Hassan said.
There’s little criticism of the $61 million that PEPFAR spent providing antiretroviral drugs and treatment to HIV-positive South Africans last year. “PEPFAR is an amazing program,” said Abdool Karim, an official with the Centre for the AIDS Programme of Research in South Africa, which receives PEPFAR funding though the U.S. National Institutes of Health. In particular, he cited PEPFAR’s funding of antiretroviral drug therapy.
But South African HIV/AIDS activists have criticized PEPFAR for pushing abstinence and faithfulness as prevention measures while de-emphasizing condom use except among a narrow segment of the population deemed to be at high risk, such as commercial sex workers and people whose spouses are HIV-positive. They say it’s perilous to make ideologically driven distinctions in a place where the disease is so rampant.
“The abstinence-be faithful message is dangerous,” said Sipho Mthathi, an official with the Treatment Action Campaign, a major AIDS activist organization in South Africa. “To tell people to ‘be faithful and you won’t get HIV’ is tantamount to telling people to cross the road blindly. More and more women are getting infected because they think they’re in a stable relationship and not at risk. But the truth is that everybody is at risk.”
Another PEPFAR critic is David Harrison, chief executive of LoveLife, an organization that carries on a high-profile outreach campaign directed at young South Africans. Its campaign includes provocative billboards and television ads, and a chain of youth prevention-education centers in places such as Orange Farm. Harrison said LoveLife, which advocates abstinence and faithfulness but also promotes condom use, was told by U.S. officials that it fell “outside the scope of PEPFAR funding.”
“The problem is that we seem to be viewed as the devil, despite the fact that the single biggest behavior reported by young people exposed to LoveLife is extended abstinence,” Harrison said.
For their part, U.S. officials deny critics’ charges that PEPFAR aims to discourage condom use. Dr. Gray Handley, who until recently served as health attachéto the U.S. Embassy in South Africa, said that, to the contrary, PEPFAR “supports the most diverse portfolio of HIV/AIDS prevention strategies of any international partner” in South Africa. “The persistent myth that PEPFAR places priority on [abstinence and faithfulness] approaches is not supported by the facts.”
PEPFAR documents show that it spent $7.6 million on condoms and condom distribution in 2005 in South Africa — about 25 percent less than the $10 million it spent promoting abstinence and faithfulness. PEPFAR funding for abstinence and faithfulness promotion more than doubled from 2004 to 2005, while spending on condoms actually declined slightly.
More important, critics contend, HIV/AIDS organizations are becoming fearful of saying too much to their clients about condoms and running afoul of a much-needed source of funding. “There are many groups we have worked with who say they are being pressured to push abstinence only,” complained Mthathi of the Treatment Action Campaign. “It becomes difficult to resist the dogmatism of the PEPFAR framework.”
Comfort level with abstinence
Not everyone sees PEPFAR’s emphasis on abstinence and faithfulness as a problem. In Whittlesea in the rugged Eastern Cape region, where brightly painted houses cling to the steep inclines of the Amatole mountain range, former pediatric nurse Joan Littlefield runs an HIV/AIDS program for Africare. Her international nongovernmental health organization received $1.5 million from PEPFAR in 2005, which went toward treatment and palliative care for HIV/AIDS patients and HIV testing and counseling, as well as a prevention program focused on abstinence and faithfulness.
The Whittlesea area is filled with small villages, some of them newly erected on what during the apartheid era was privately owned farmland. Because the villages don’t have deep generational roots, Littlefield explained, religion has become an even more important part of the community fabric. “It is a very church-based culture here,” she said.
Littlefield said that deeply religious locals are far more comfortable with abstinence and faithfulness. “Even male leaders feel that faithfulness needs to be emphasized,” she added. Some church leaders, she explained, don’t want to hear about condoms — and many don’t want local teenagers hearing about them either.
So instead of handing out condoms to young people — something that wouldn’t be allowed under PEPFAR guidelines anyway — Littlefield prefers to advocate abstinence. “What we hope to do,” she said, “is saturate the communities, reaching different kinds of people from their own perspective — youth groups, church, etc. — so that we reach most of the community with messages around prevention and reducing stigma.”
For example, Littlefield’s program has helped train village elders who guide teenagers through various rites of passage to manhood, so that they can provide information about HIV/AIDS prevention to the youths as well. Young people also have been trained to serve as peer educators in the villages.
“The expectation is that there will be less denial and more prevention and testing if we provide consistent messages from all fronts that emphasize prevention, testing, what care is available if positive and caring for those who are,” Littlefield said.
Meanwhile, in the Kommetjie valley in the Western Cape, the Rev. John Thomas is determined to do something about the “terrible dilemma” that young people face because of “TV programs that say you can jump into bed with everyone.” He’s the board chairman of the Living Hope Community Centre, a Baptist church organization that receives PEPFAR money in addition to funding from the Global Fund to Fight AIDS, Tuberculosis and Malaria, the European Union, and other government and private sources.
“Living Hope provides a range of services, from literacy classes to aid to the homeless, to the inhabitants of Masiphumelele, a ramshackle settlement on the edge of an affluent coastal town. PEPFAR provided about $385,000 in 2005 to Living Hope’s prevention efforts. According to PEPFAR documents, the program includes a 12-week course on HIV/AIDS offered through a local hospital and medical clinic. For children and teenagers, Living Hope organizes weekly clubs where they receive training “to enable youth to resist sexual pressures” and remain chaste until marriage.
Living Hope’s prevention program became the subject of controversy earlier this year, when a Religion News Service article described an HIV/AIDS education course the organization gave to a group of local sangomas, or faith healers. The news agency reported that in addition to instruction in the signs of AIDS and the functions of antiretroviral medications, Bible reading was a required part of the curriculum. The faith healers “came to us knowing very well what we stand for and knowing that this is God’s thing,” Living Hope chaplain Nobuntu Matholeni was quoted as saying. “We want to continue with the course, but we have to do this work through the Lord Jesus Christ.”
Treatment Action Campaign spokesman Nathan Geffen accused Living Hope of mixing HIV/AIDS education with evangelism. “To try and offer medical training, but make that knowledge contingent upon changing people’s religious views, that I find obnoxious,” he told Religion News Service.
Thomas said that no PEPFAR funding has been used for proselytizing and insists that, contrary to the article, the religious part of the HIV/AIDS course was strictly voluntary. “We don’t require anybody to attend any devotional activities,” he said. “But it is how we run our program.” He added that another group of sangomas asked for the training course. “Ninety-eight percent of the time, they will be getting biological and medical facts,” he said. “But they will get a Bible reading — that’s just the way we work.”
Prevention program emphasizes religion
In other PEPFAR-funded faith-based programs in South Africa, the line between religion and HIV/AIDS education may be even blurrier. One example is CompreCare Joint Venture, a Tshwane-based organization that received $527,000 in PEPFAR money in 2005.
CompreCare was founded in 2004 by Andréde la Porte and Hannes van der Walt, activists in the Dutch Reformed Church (a notorious bulwark of the apartheid system until it embraced racial equality in the mid-1980s). (De la Porte is also managing director of HospiVision, a health care organization connected with the church.) CompreCare’s program manager is Andre Bestbier, a former major general in the South African military whose understanding of HIV/AIDS is filtered through martial metaphors — “How will we win the war?” he asks.
Neither of CompreCare’s principals has public health credentials — van der Walt’s doctorate is in theology; de la Porte’s is in pastoral counseling. But then again, CompreCare doesn’t actually provide any public health services. Instead, it’s a funding conduit for a handful of other organizations that perform the work. Some of the money it receives from PEPFAR, for example, goes to support Child Welfare Tshwane, which conducts home visits to families affected by HIV/AIDS.
But CompreCare’s religious emphasis is most evident in its Choose Lifeprevention program, which was developed and is still presented by HospiVision. Unlike most prevention programs, Choose Life doesn’t directly engage the at-risk population. Instead, the five-day training course is intended for pastors, church leaders and members. “In this programme you will explore knowledge, attitudes and perceptions about HIV and AIDS,” a brochure explains. “You will be empowered to combat HIV and AIDS through ethical and spiritual conduct. You will discover how to transform your community into an ethical community.” Despite the U.S. funding, the courses aren’t cheap. Choose Life charges a registration fee of 200 rand (about US$27) — about 10 times the average daily income for the poorest half of South Africa’s households.
Choose Life is teaching its presumably affluent participants to be trainers, who then presumably go out and train others. “We have a target of 216,” Bestbier said. “If we can push that up to 500 advanced trainers, they will train people, and eventually we will have reached 27,000 people. It’s like the days when we fought the counterrevolutionary war. They called it the ‘oil patch concept.’ If you put oil on paper, it gets bigger and bigger. That’s what we want to do.”
What are the trainers learning? Mostly, they’re getting a course in Christian ethics — Unit 5 in Choose Life’s training manual, for example, deals with “Maintenance of (a) Christian Value Based Lifestyle,” while another section deals with “Theological reflection on HIV and AIDS.” Participants are asked to ponder scriptural passages such as Genesis 39: 1-23 (“Does Joseph’s predicament have anything to say to us today?”)
Of the 276 pages in the Choose Life program manual, just a few pages are devoted to information about HIV/AIDS and how it is transmitted.
The Choose Life curriculum doesn’t totally dismiss the value of condoms, but the manual states succinctly that “the focus in this program is A&B,” a reference to the Abstinence and Be Faithful component of the ABC approach to HIV prevention used by the U.S. government. “C” stands for correct and consistent use of Condoms. De la Porte insisted that “we are very clear on the fact that condoms are essential and valuable, but only within the context of values such as respect, responsibility and integrity.”
Bestbier was less circumspect. “The core of the entire program is that prevention is Abstinence and Be Faithful,” he said, “That is the answer. Our philosophy is value-based, faith-based, whatever you want to call it. … By condomizing, you’re telling people by implication that it’s OK to have sex as much as you like, as long as you use condoms.”
Desperate for help
While PEPFAR funding goes to support Choose Life’s mix of theology and HIV/AIDS education, the shack dwellers in Orange Farm grow increasingly desperate for help of any kind. The Rev. Guy Bourgeois, a Catholic priest from Quebec, runs the Inkanyezi HIV/AIDS organization in Orange Farm, a network of nine satellite clinics set up in cinder-block sheds that provides antiretroviral drugs to 120 people and home care and counseling to 400 more. Some of Bourgeois’ patients are so sick that they must be brought to the clinic in wheelbarrows, because the privately funded organization is too poor to have an ambulance. But as he told The (Montreal) Gazette in April, the people he’s able to help amount to only a tiny fraction of those who need help. “There must be 80,000 to 90,000 [HIV-positive] people here,” he said. “Maybe more.”
Rose Thamae, another Orange Farm HIV/AIDS caregiver and activist, challenged PEPFAR officials to “come and see what is happening here.”
“I am uneducated, and so are most people here,” she said. “But please, we also fit the criteria.” She pleads: “Maybe you know somebody who can help us get the papers?”
Anna-Maria Lombard is a television documentary producer based in Bergbron, South Africa. Adri Kotze is a television documentary producer based in Johannesburg.
