The gardener's tragedy: Face of a country in crisis

A South African's HIV-positive relative is dead. Now he must help pay for her funeral. Worse, he may be infected too.


JOHANNESBURG, South Africa -- The knock at the gate was our gardener, Shephard Moyo. He had come by just to get a ladder, but his pained expression made clear something was terribly wrong.

"I have a very big problem," he said, standing in the bright sunshine a couple weeks ago. His cousin's 30-year-old wife had just thrown herself off a fifth-floor balcony in downtown Johannesburg.

The day before, she had learned she was HIV-positive. Maybe she was unaware of the potential availability of treatment or could not face the stigma. Maybe she simply came unhinged. Whatever it was, this mother of a 10-year-old girl chose to end her life.

AIDS is a delicate subject in South Africa. Evidence of the disease is all around but seldom recognized: About one in six adults has the virus, but few people talk openly about it. I saw a rare opening to ask Moyo questions usually considered a no-go zone. I was curious but also concerned because he'd been looking gaunter than usual, his eyes bloodshot.

Moyo told me he is HIV-negative - or at least he was the last time he got tested, in 2002. Since then, he revealed, he has slept with several women other than his wife. He asked me a jarring question: Can you get HIV if you don't use a condom but withdraw before ejaculating?

When I told him sex is never safe without a condom, he looked shocked. It was my turn to look shocked when he admitted that he didn't always use a condom even when he finished intercourse with other women.

"You realize it's a mistake, but you lose control," said Moyo, who's in his mid-30s, "and at the end of the day you've done it."

For all the millions of dollars spent here on prevention, a lethal combination of ignorance and recklessness continues to fuel an epidemic that afflicts 40 million lives worldwide. Moyo reads newspapers, sees the ubiquitous anti-AIDS placards, yet somehow he missed an obvious survival lesson in modern-day South Africa.

"The message is not getting out," said Olive Shisana, lead author of a new national HIV survey conducted by South Africa's Human Sciences Research Council, of which she is executive director.

Highway billboards say "Don't be a fool" and "No to unsafe sex" and "AIDS kills." One of the best-known awareness campaigns reminds youths that they are "born free" and should remain so.

But Shisana says what's needed are "crystal clear" messages about consistent condom use and periodic HIV tests. It goes beyond that: AIDS activists and others would say President Thabo Mbeki, who's typically quiet on the issue, needs to use his office as a bully pulpit to rally the nation against the scourge.

Sub-Saharan Africa remains the epicenter of this disease. About 26 million people in the region live with HIV/AIDS, including 3 million newly infected in 2005. (AIDS claimed the lives of an estimated 2.4 million in the region this year.) Two-thirds of the global HIV-positive population live in the region, as do 77 percent of all women with the virus.

Although Kenya, Uganda and Zimbabwe have shown improvement, an AIDS report released last month by the United Nations and the World Health Organization says the disease is expanding in Swaziland and Mozambique and at the very least holding steady here in South Africa.

Shisana's survey, commissioned by the Nelson Mandela Foundation, found that South Africa's adult HIV rate seems to be "leveling off" around 16 percent, but that may just mean new infections are keeping pace with AIDS-related deaths. Lack of awareness is a major factor behind the new infections. Among the survey's findings:

Nearly one-fifth of young people ages 12 to 14 did not understand the concept of sexual transmission, and nearly one-third did not know that HIV can pass from mother to newborn.

Forty percent of those surveyed across all age groups did not know, or were unsure, that a person can infect another with HIV while receiving antiretroviral treatment.

About one-third disagreed or were uncertain about whether the risk of HIV infection could be reduced by having fewer sexual partners.

"At the moment, the picture is rather bleak," said Richard Delate, a spokesman for the UN's AIDS program in Johannesburg. "There is a rising number of infections and an increasing number of deaths."

Delate and Shisana see some bright spots in South Africa. Condom use is up, thanks in part to the government's distribution of 300 million a year. People are more likely to get tested now that antiretroviral drugs are slowly becoming more widely available.

But huge worries remain. Females ages 15 to 24 are acquiring the virus at eight times the rate of their male counterparts. The trend stems from a "sugar daddy" phenomenon in which young, usually poor, women swap condom-free sex with older men in return for gifts and cash.

Women in their late 20s are also catching the virus in great numbers: One-third of women 25 to 29 are HIV-positive. In part, the numbers reflect gender inequalities that make it difficult for many women to insist their partners use condoms.

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