Letting Them Die: Why HIV/AIDS Prevention Programmes Fail: Why HIV/AIDS Prevention Programmes Often Fail (African Issues) [Paperback]

The book describes the author’s experiences with a project that started out by trying to reduce the risk of infection by HIV amongst three groups in a mining town in South Africa – female sex workers, male miners, and young people. There were two approaches to doing this: peer education and the “promotion of partnerships between a diverse array of community groupings of stakeholders to coordinate and support the variety of local HIV-prevention efforts in such a way that maximized their overall cumulative effectiveness”. The interventions chosen were all invested with the glowing approbation of the international ‘AIDS project’ community as prime examples of what should be done in such situations. In terms of having any impact on the epidemic or on the sexual culture of the area the project has so far been a failure. The author analyses the reasons for this failure in a number of analytical contexts.

The author is very well placed to analyse the history of the project. She herself as a social psychologist had been involved in the township in 1995 in trying to understand the reasons why there is such a high prevalence of HIV infection amongst the miners and sex workers despite their obvious knowledge of the existence of HIV and the ways in which it is transmitted. The studies themselves form part of the opening chapters, and provide very good insight into the conditions of these people’s lives and the enormous social factors that influence their lives and decision-making. The following chapters describe the way the project grew as a result of a drive from some local people for work that would affect the growing numbers of people with AIDS and from a group of scientists and professionals (including the author) who had an interest in the area. One chapter provides the initial theoretical justification for the various actions that were taken, with heavy leaning on the writings of Paulo Freire on the conscientisation side, Pierre Bourdieu for social capital, and on the experiences of peer education with sex workers in Zimbabwe of David Wilson and others.

The book will be invaluable for the discussion of the importance of the social context for behaviour, and indeed will be read by many for that alone. It also details the very many ways in which the project’s ideals fell by the wayside (the rates of sexually transmitted infection in miners actually rose during the period of the project, there were many difficulties with the peer education approach for young people in school, the stakeholders were far from unified in their vision or even interest) or were partially successful (there were several changes amongst the sex workers), and again these experiences will be as interesting as they are familiar to many who work with such projects.

However this book goes far beyond such a discussion. She points to the inadequacies of our current theoretical and modelling frameworks for such interventions; to the fact that the stakeholders who were involved did not see themselves as part of the epidemic or as people whose behaviour had to change; to the fact that the designers and researchers of the project had much discord and competition amongst themselves; to the great mistrust that developed between the researchers and much of the ‘community’. In fact, although the author tries to scotch the problem with the definition of ‘community’ by stating that in this case the term ‘community’ refers to the people in a geographic area, the tension behind this definition continues throughout the book as it is acknowledged that only a few of the many individuals and groups in the area were in fact being requested to change their ways – the paternalism and continued power of the ‘senior’ stakeholders continuing throughout.

The value of the book is still more. The lessons drawn in the concluding chapter smack of a level of desperation in the author to find lessons, and this may perhaps be the only weakness of the book. In these lessons the author still struggles to keep the idea going that somehow in a better world the interventions could have had an impact if only people had carried them through according to the wishes of the project designers. The deep question the author raises in the mind of the reader is whether such approaches can ever work in relation to an epidemic (as opposed to being valuable for a few individuals or groups). This question is not actually present in the book (although there are numerous hints of the author’s disquiet concerning the mismatch between the daily reality of people’s lives and the wishes and interests of the project managers) but it hangs over ever sentence as did the sword over Damocles. As for Dionysius in relation to those who wield power, it is a question hanging over all those who praise mindlessly the black art of development.