Mail and Guardian (Johannesburg) - August 31, 2005
David Harrison*: RIGHT TO REPLY

It is a pity that Singer didn't spend as much time interviewing young people as she did the well-known clutch of middle-aged loveLife detractors. If she had, she might have better understood the "born-free generation" growing up with disease and democracy. Instead, Singer buys into the simplistic premise that if young people just got the "right message", they would perceive the risks and consequences of their actions and abstain from sex.

This is a view propagated by many outside experts who think they know what's good for Africa. But, the fact is, the only thing inter-national experience conclusively illustrates is that there is no magic formula for HIV prevention. We also know from international evidence that behaviour change is arduous and incremental, requiring efforts of sufficient scale and duration. As eager as loveLife's critics are to discredit the campaign, it is far too soon to rush to judgement on its impact.

loveLife does not claim to have found the holy grail of HIV prevention, but it is a serious evidence-based effort that goes beyond the simplistic "use a condom or die" approach - the staple of HIV prevention for nearly 25 years. That approach has produced little to brag about. Rather loveLife gets to grips with the primary factors driving the HIV epidemic, which are as much entrenched in the norms of South African society as in the rationality of individual decision-making.

Sexual coercion, gender inequality and avoidance of family discussion about sex and sexuality are primary predictors of high-risk behaviour, including age of first sex, condom use and number of sexual partners. Compounding these social determinants are poverty and low education, with poorer and less-educated teenagers more likely to have had sex. Yet the relationship between poverty and HIV is not invariable, and young people with a keen sense of self-esteem and purpose are less likely to be infected - regardless of socio-economic status.

This insight has critical implications for HIV prevention. First, we must achieve massive social mobilisation, which won't be triggered by HIV awareness alone, but by a strong sense of identity with a new way of life - the born-free generation striving to be Aids-free. Second, individual choice is shaped not by knowledge alone, but by personal motivation and sense of self-efficacy. We must not only inform young people but inspire them. Third, our efforts at social change will be limited if young people continue to feel trapped in poverty. It is not good enough for us to point to broader socio-economic empowerment; we must be part of those efforts.

A point often lost on critics of loveLife is that among its target group of 12- to-17-year-olds, only a third are sexually active and fewer than 2% are HIV- positive. Abstinence and delayed sexual debut, HIV-testing, the early treatment of sexually transmitted infections and safer sex form a central part of loveLife's communication, but we aim to shape attitudes even more profoundly. This is the basis for loveLife's approach: tapping into the innate optimism of young people to promote aspirations and healthy living, while strengthening the institutional response to young people's needs in government clinics and schools.

Contrary to Singer's assertions, we do not claim success in bringing down HIV rates among teenagers, but neither do we subscribe to the knee-jerk response that "rates are high, so nothing's working". In fact, according to a national survey of 12 000 15- to-24-year-olds in 2003, 63% say they have changed their behaviour to avoid HIV infection. Of these, 20% reported using condoms, 14% reported reducing their number of sexual partners, and 13% reported abstaining from sex. The survey also found significantly lower HIV-infection rates among participants in loveLife's programmes, taking into account other explanatory factors. This effect is even more pronounced with higher levels of exposure to loveLife. This encouraging evidence provides some strategic direction, although we do not say that loveLife caused the lower rates of infection.

We may never be able to precisely pinpoint the impact of loveLife, but the ultimate measure of loveLife's contribution will be in the trends in HIV infection among teenagers and young adults. It's here that cynical and misinformed analysis could be so destructive in masking early gains. For example, Singer asserts that "about one in 10 teenagers is HIV-positive". Actually, it's just more than 5%.

* David Harrison is loveLife's CEO

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