IAVI Report - December 2000 / January 2001
Anne-christine d'Adesky

It's easy to see why Carletonville has become an epicenter for South Africa's AIDS crisis. Every day, some 70,000 migrant miners work grueling shifts in the largest gold-mining complex in the world. Many emerge after sunrise from the bowels of the mineshaft and spill into the cramped quarters of ten single-sex male hostels nearby, where up to 15 miners share a room. Before sleep, they often wander over to makeshift foodstalls or to the shebeens — informal shacks where home-brewed beer is sold along with sex by commercial sex workers. It is in these "hotspots," as they are known, that the HIV epidemic has taken off, fueled by the intertwined factors of poverty, alcohol, violence, and the miners' fatalistic attitude about their own survival. "The miners say, quite correctly, that in 10 years the rocks or dust will kill us, so why should we worry about HIV?" explains Brian Williams, a South African epidemiologist who heads the Mothusimpilo ("Working Together For Health") HIV/AIDS Outreach Project there, under the auspices of the Council for Scientific and Industrial Research. "In the meantime we might as well have a good time."

There are 12 mines in the Carletonville district, a 25 kilometer-square area that includes the historically white town of Carletonville (population 20,000), the largely black township of Khutsong (population 150,000) and smaller residential areas where migrant squatter settlements have also emerged as HIV trouble-spots. Williams began working there in the mid-90s, when he was hired to study overall health conditions among miners.

What he found was a skyrocketing HIV epidemic that flourished in a setting of poverty, danger and sex, along with rampant, untreated STDs. HIV prevalence was 4-5%, he says. By 1998, 22% of the mineworkers he sampled had HIV, while an astonishing 50% of the 24-year old local women also tested positive. For local males, the peak comes later, but the outcome is similar: 8% are positive by age 20, and by age 32 that figure has climbed to 45%. Among Carletonville's commercial sex workers, some 70% are now infected. Combine this with the fact that 90% of the miners are migrants — some from neighboring countries of Lesotho, Mozambique and Botswana — and it becomes clear why HIV spreads so fast from this mining hotspot.

The Carletonville Project springs from a 1995 meeting that brought Williams together with mining and union officials, mine workers, community leaders, and professional colleagues such as Catherine Campbell of the London School of Economics and Liz Floyd, director of the AIDS program in the greater province of Gauteng. It led to the Mothusimpilo Project, launched in August 1997 to develop a sustainable, community-based intervention to evaluate the impact of STDs and HIV in Carletonville.

Participants of the first meeting formed a skeleton advisory group for the project; Campbell and Floyd became teammates. With US$1 million in grant money from USAID and the British Department for International Development (DFID), they reached out to others with a stake in the local community, such as the national and provicincial health departments, mine management, research organizations and local NGOs, a strategy meant to ensure community "ownership" of the project. Their immediate goal was to provide syndromic management of STDs while working closely with traditional healers. They also wanted to recruit miners and "hot spot" sex workers into a sustainable HIV peer education and condom distribution project.

The first phase of their work involved assessing community needs and identifying potential outreach workers. Next came the epidemiological surveys of HIV and STD rates. Once a year, they did anonymous cross-sectional surveys of 1,500 people aged 15 to 30, including 1,000 miners and 100 sex workers from the hotspots. The surveys included screening for HIV and STDs (carried out at the South African Institute for Medical Research in Johannesburg) and administering an extensive questionnaire adapted from one used by UNAIDS for its multicenter studies elsewhere in Africa. The last phase, now being completed, is an analysis of the project's successes and shortcomings.

When they began there was little AIDS awareness in the Carletonville community; in its place was fear, stigmatization and denial. "No one was interested in HIV," Williams says bluntly. Nor did anyone know much about community attitudes and behavior around HIV. "So we spent the first two years talking to sex workers, and learning a lot." What was urgently needed, they found, was HIV support groups, counseling for rape, alcoholism and pregnancy, and job training and housing assistance — areas where local NGOs had a role to play.

With four major ethnic groups in Carletonville, the team also learned how to tailor educational messages in culturally sensitive ways, and to scrutinize how those messages are received. By recruiting and training miners and sex workers, they have developed a committed team of outreach workers. "It's very basic stuff," Williams says of the peer training program. "You give them a two-week course on STDs and physiology, and at that level it's working."

But their biggest success has come from the intense focus on STDs. "We've had a fairly dramatic effect because the women realized early on that they were no longer getting STDs," he says — a major incentive for community involvement in the project. Tens of thousands of condoms later, the safe-sex message is spreading and is being carried into high schools by youth peer educators. But success has not been uniform: while the highest-risk women have developed a very active program of peer education, reports Williams, "peer education among mine workers has been less successful, mainly because the industry is unwilling to allow men time off work to be trained." He's more hopeful about school-based interventions — the project's new frontier, born out of the early, unexpected findings that adolescents, primarily females, have such high rates of infection.

The clear link between treatable STDs and HIV has also been incorporated into their strategy. Earlier this year, with the backing of USAID and the Population Council's Horizons Project, the Carletonville team initiated Presumptive Periodic Treatment (PPT) of STDs, using a mobile health unit to treat those at high risk for STD re-infection before they become symptomatic. A similar program at the gold fields of the Free State province showed that PPT of sex workers has led to a substantial decline in STDs among mineworkers.

The PPT program will run until August 2001 and be evaluated immediately afterward. But results are already encouraging. "STD rates are going down dramatically in sex workers," reports Johannes van Dam, deputy director of the Population Council's Horizons Project, which funds the PPT program. To him, the program's other achievements are the "enormous increase in condom distribution" and the greatly increased awareness of HIV/AIDS in the community at-large.

Perhaps the biggest measure of success is the local community's desire to now manage the Carletonville project. "It has always been our expectation that the intervention site be taken up by local groups," says van Dam. "That shows they have become self-sufficient." While it may take months for the various players to sort themselves out, one of two mining groups has agreed to fund the next phase of activities, and local and municipal authorities are signing on. Plans include a trial to examine the effect of male circumcision on HIV transmission and a study of who young girls are having sex with, and why — an attempt to find out "where the chain of infection is vulnerable to intervention," says van Dam.

Turning to HIV vaccines, van Dam says there's no active discussion of possible trials in Carletonville now, but that it is potentially "a very attractive site" given the high rates of HIV and the community infrastructure in place. With teenage girls at such extreme risk, "they are one of the groups you want to test a vaccine on," he states. "By the time they are adults, it will be too late." Williams agrees, suggesting that vaccine advocates begin tackling the thorny ethical issues of testing HIV vaccines in adolescents. He also points to the need for preliminary groundwork to assess community attitudes towards vaccines and trials.

But the capacity and trust built up over the years would provide a strong foundation. "We've built up a cadre of very committed people. Giving them additional training in vaccine work would be quite straightforward." For his part, Williams hopes to test an experimental genital herpes (HSV–2) vaccine there and is seeking funding for such a trial. That could also provide a stepping stone to future HIV vaccine trials, in terms of preparing the community and the laboratory and logistical infrastructure.

What about miners as a potential vaccine cohort? Here, there are special challenges and clear advantages. "The mining industry is a bit of a law unto itself," Williams says ruefully. "They can be very controlling." But from a research perspective, the mines are well-financed, private entities that offer free, high-quality medical care to workers in mine hospitals equipped with state-of-the-art technology and drugs. And "logistically the mines are an absolutely ideal place to do a vaccine trial," notes Williams. Adds van Dam: "The mining houses have labs as good as they get around here, but they could be really upgraded to do vaccine research."

Yet on the ground in Carletonville, every day without progress towards a vaccine can seem like another step towards the dark scenario projected on Williams' computer, in the numbers and logarithmic waves of infection. "You're sitting in Carletonville where nearly 70% of all 25-year-old girls are HIV-positive and they are going to die in the next five to ten years," Williams sums up darkly. "We need something unbelievably drastic if we're going to save even half of them. If you cannot protect them, then everything is lost. It's an almost unimaginable situation."

001210
IAVI2000-120110

©2000. The IAVI Report.

ÆGiS is made possible through unrestricted grants from Roxane Laboratories, Inc., iMetrikus, Inc., the National Library of Medicine, and donations from users like you. Always watch for outdated information. This article first appeared in 2000. This material is designed to support, not replace, the relationship that exists between you and your doctor.

ÆGiS presents published material, reprinted with permission and neither endorses nor opposes any material. All information contained on this website, including information relating to health conditions, products, and treatments, is for informational purposes only. It is often presented in summary or aggregate form. It is not meant to be a substitute for the advice provided by your own physician or other medical professionals. Always discuss treatment options with a doctor who specializes in treating HIV.

Copyright ©1990, 2000. ÆGiS & the Sisters of Saint Elizabeth of Hungary. All materials appearing on ÆGiS are protected by copyright as a collective work or compilation under U.S. copyright and other laws and are the property of ÆGIS and the Sisters of Saint. Elizabeth of Hungary, or the party credited as the provider of the content.